Whiplash Injuries and the Elderly

Concept and Terminology

A common cliché is that the only certainties in life are death and taxes. Another certainty for the elderly is the increasing incidence of the wear-and-tear breakdown of one’s joints. The presence of joint breakdown increases with age at all joint sites.

These joint breakdowns have a number of names:

• Arthritis
• Osteoarthritis
• Degenerative Arthritis
• Degenerative Joint Disease (DJD)
• Spondylosis, primarily applied to the spinal facet joints
• Spondyloarthritis, again primarily applied to the spinal facet joints
• Degenerative Disc Disease (DDD)

Osteoarthritis is the clinical and pathological outcome of a range of disorders that results in structural and functional failure of synovial joints. Osteoarthritis may also occur in the intervertebral disc.

In 2006, researchers from the University of Medicine and Dentistry of New Jersey published a study in the American Journal of Physical Medicine and Rehabilitation titled (1):

Osteoarthritis
Epidemiology, Risk Factors, and Pathophysiology

The authors note that osteoarthritis is the most prevalent form of arthritis and a major cause of disability in people aged 65 and older. Osteoarthritis affects the majority of adults over age 55:

• 58% of those older than 70 years have symptomatic osteoarthritis.
• 10-30% of those with osteoarthritis have significant pain and disability.

 There are two major risk categories for osteoarthritis:

• Systemic factors: age, ethnicity, gender, hormonal status, genetics, and nutritional (especially increased levels of oxidative stress and decreased levels of antioxidants).
• Local Factors: abnormal biomechanical loading, obesity, ligamentous laxity, malalignment, impaired proprioception, muscle weakness.

 When systemic factors are present, the joint is more vulnerable to local biomechanical factors; local joint biomechanical factors will have more of an impact on joint degeneration. High-intensity direct joint impact increases the risk of osteoarthritis in the affected joint.

•••••

In 2015, researchers from Mayo Clinic, the University of Washington, Oregon Health and Science University, University of California San Francisco, and Kaiser Permanente in Oakland, California, published a study in American Journal of Neuroradiology titled (2):

Systematic Literature Review of Imaging Features
of Spinal Degeneration in Asymptomatic Populations

The objective of this study was to estimate the prevalence, by decade age (20, 30, 40, 50, 60, 70, 80 years), of common degenerative spine conditions. The authors performed a systematic literature review studying the prevalence of spine degeneration on imaging of 3,110 asymptomatic individuals taken from 33 studies that met their inclusion criteria. The imaging modalities used to assess the changes were either CT and/or MRI. The authors documented:

• Disk degeneration
• Disk herniation
• Annular fissures
• Facet degeneration

Asymptomatic individuals were those with no history of back pain. Studies with patients with minor or low-grade back pain were excluded, as were patients with motor or sensory symptoms, tumors, or trauma.

The authors note that degenerative spinal changes often occur in pain-free individuals as well as those with back pain. Prior studies have shown spinal degeneration present in a large proportion of asymptomatic individuals. “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”

The findings in this study included:

“Disk degeneration prevalence ranged from 37% of asymptomatic individuals 20 years of age to 96% of those 80 years of age, with a large increase in the prevalence through 50 years.”

“This systematic review indicates that many imaging findings of degenerative spine disease have a high prevalence among asymptomatic individuals.”

“Our study suggests that imaging findings of degenerative changes such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”

“With a prevalence of degenerative findings of >90% in asymptomatic individuals 60 years of age or older, our study supports the hypothesis that degenerative changes observed on CT and MR imaging are often seen with normal aging.”

The key concept from this study is that spinal arthritic changes are very common in the elderly (>60 years of age). Yet, these arthritic changes are largely asymptomatic. However, consistent with above (1) and explored in detail below, arthritic joints are less capable of adequately handling and dispersing traumatic loads as compared to nonarthritic joints. The consequences of such injuries include:

• Increased Injury
• Increased Pain and Disability
• Longer Recovery Time
• Acceleration of Spinal Degenerative Processes
• Increased Risk of Permanent Residuals
• Increased Need for Ongoing and Future Healthcare Interventions

A critical concept is that in the elderly (>60 years of age), essentially all persons, including those who are asymptomatic, have preexisting spinal arthritic changes.

•••••

In 1964, a study published in the American Journal of Orthopedics, titled, The Positive Findings in Neck Injuries, noted (3):

Pre-existing pathological conditions of the cervical spine, when injured, “result in more damage than would be anticipated in a so-called ‘normal’ cervical spine.”

•••

In 1977, the authoritative reference text, Orthopaedic Principles and Their Applications, states (4):

“The injury may be compounded by the presence of degenerative disease of the spine.”

“With advancing age, especially in the presence of degenerative disease, the tissues become inelastic and are easily torn.”

•••

In 1981, the book Neck and Arm Pain, states (5):

“The pre-existence of degeneration may have been quiescent in that no symptoms were noted, but now minor trauma may ‘decompensate’ the safety margin and symptoms occur.”

•••

In 1983, a study published in the Journal of Bone And Joint Surgery (British), titled, The Prognosis of Neck Injuries Resulting From Rear-end Vehicle Collisions, followed 61 whiplash-injured patients for a minimum of six months in order to establish factors that were prognostic for recovery. Their conclusions include (6):

“Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, [loss of cervical lordosis], and pre-existing degenerative spondylosis.”

Degenerative spondylosis was detected in 26% of patients with no objective findings, 33% of patients with reduced cervical range of motion, and 40% of patients with neurological loss, indicating that cervical spine degenerative changes are associated with greater injury and worse prognosis for recovery.

“Pre-existing degenerative changes in the cervical spine, no matter how slight, do appear to affect the prognosis adversely.”

“The prognosis may be modified by the presence or absence of degenerative changes, by an abnormality [degeneration] of the cervical spine on the initial radiograph, or by both.”

•••

In 1985, a study published in the Journal of the Australian Chiropractors’ Association, titled, Mechanisms and Patterns of Tissue Injury noted (7):

“Degenerative joint disease is recognized as a major influence on subsequent tissue damage both in severity and pattern.”

“In any individual where changes consistent with degenerative joint disease are present, one can expect the injury to be more severe or a very minor injury to produce severe symptoms requiring prolonged treatment.”

•••

In 1986, a study published in the journal Canadian Family Physician, titled, Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury; noted (8):

“For the elderly, neck injury can be very serious. The degenerative spine is biomechanically ‘stiffer’, behaving more like a single long bone than like a set of articulating structures.  Deforming forces are less evenly dissipated, and more damage is done.”

•••

In 1987, a study published in the journal Instructional Course Lectures, titled, Soft-tissue Injuries of the Lower Cervical Spine, noted (9):

“If present, degenerative changes should be duly noted as they may affect the prognosis.”

“…pre-existing degenerative changes adversely affected the outcome.”

•••

In 1988, a study published in the journal Injury, titled, Whiplash Injuries of the Neck, reviewed 102 whiplash-injured patients 2 years after injury. They concluded (10):

“The analysis of the radiological results showed that pre-existing degenerative changes in the cervical spine are strongly indicative of a poor prognosis.”

•••

Also in 1988, a study published in the journal Orthopedics Clinics of North America, titled, Whiplash Syndrome, Fact or Fiction?, noted (11):

Pre-existing structural changes and degenerative changes are “frequently associated with a more difficult, more prolonged, and less complete recovery.”

“The films should be inspected especially for evidence of pre-existing structural changes or for alteration, which are frequently associated with a more difficult, more prolonged, and less complete recovery.”

•••

The 1988 reference text titled Whiplash Injuries, The Acceleration/Deceleration Syndrome, noted (12):

“…the presence of preexisting degenerative changes, no matter how slight, appears to alter the prognosis adversely.”

•••

In 1989, a study published in the British Medical Journal titled Neck Sprains After Car Accidents, noted (13):

“Pre-existing degenerative changes may worsen the prognosis.”

•••

In 1991, a study published in Injury titled Prognostic Factors in Soft Tissue Injuries of the Cervical Spine, radiographically reviewed 35 whiplash-injured patients 10.8 years after injury. The authors concluded (14):

“Patients with degenerative change initially have more symptoms after 2 years than those with normal radiographs at the time of injury.”

“Degenerative changes occurred significantly more frequently in patients who had sustained soft tissue injuries than in a control population.”

Also in 1991, the reference text Painful Cervical Trauma, Diagnosis and Rehabilitative Treatment of Neuromusculoskeletal Injuries, noted (15):

“The elasticity of tissues decreases with an increase in age. The range of motion in the cervical spine also decreases. In both cases, the potential for injury is increased because the neck is less resilient.”

•••

In 1995, a study published in Spine, titled: Successful Treatment of Low Back Pain and Neck Pain after a Motor Vehicle Accident Despite Litigation, noted (16):

“Pre-existing degenerative changes on initial x-rays, no matter how slight, had a worse prognosis.”

•••

In 1996, a study published in the British Journal of Bone and Joint Surgery, titled Soft-tissue Injuries of the Cervical Spine: 15-year Follow-up, published a 15.5-year follow-up evaluation of 40 patients who had been injured in a motor vehicle collision. The authors noted (17):

“The patients who had deteriorated were on average five years older than the rest of the group.”

“80% of the patients who had deteriorated in the last five years had degenerative changes.”

“100% of patients with severe ongoing problems had cervical degeneration at 11 years after injury.”

•••

In 1999, the reference text Whiplash and Related Headaches, noted (18):

Risk factors that may lead to chronicity include “pre-existing degenerative osteoarthritic changes.”

“Other conditions that may pre-exist the accident that may contribute to a chronic state following the accident are osteoarthritis, degeneration of vertebral body joints, disc degeneration and inflammatory processes.”

“Studies indicate that pre-existing osteoarthritic changes contributed to alter the prognosis adversely.”

•••

In 2002, the reference text titled Whiplash, noted (19):

“Several researchers have associated poor clinical outcomes with spondylosis, reporting a higher prevalence of spondylosis in patients with continued symptoms.”

“It is certainly theoretically possible that symptoms from a previously asymptomatic cervical spondylosis are precipitated by trauma and are responsible for the continuing pain.”

•••

In 2005, a study published in Acta Neurochirurgica, titled Whiplash injury, TOS and double crush syndrome, Forensic medical aspects, noted (20):

A substantial percentage of people will have whiplash symptoms for more than a few months, “especially the elderly or those with pre-existing neck problems who may develop chronic long-term problems which may never resolve.”

•••

In 2005, the reference text titled Motor Vehicle Collision Injuries, noted (21):

“Patients who have clinically significant pre-existing medical conditions [including spinal degeneration] may have more severe injuries, slower recoveries and poorer prognoses.”

•••

Recently, in 2019, a study published in The Spine Journal titled Association Between Cervical Degeneration and Self-perceived Non-recovery After Whiplash Injury, followed 121 whiplash-injured subjects, aged 16-70, prospectively for six months with CT scan (22). The aim of this study was to investigate associations between cervical degeneration and non-recovery after whiplash injury, addressing both disc degeneration and facet joint degeneration.

At 6 months, only 38% of the group had recovered from their injuries, and 62% had NOT recovered.

The authors note that the majority of post-whiplash injury pain is facetal in origin. Their investigation showed an association between facet joint degeneration and non-recovery from whiplash injury:

• 70% of the non-recovered subjects had moderate facet joint degeneration
• 24% of the non-recovered subjects had no facet degeneration                   

The authors noted:

“This study demonstrates an increased risk for non-recovery after whiplash trauma for patients with moderate facet joint degeneration as demonstrated on CT scans performed shortly after trauma.”

“When facet joint degeneration and disc degeneration were included in a total score of degeneration the association remained robustly significant.”

“We suggest that one of the underlying mechanisms of WAD may be that trauma triggers a painful clinical manifestation of underlying, previously asymptomatic, cervical facet joint degeneration.”

Pre-injury “cervical degeneration, especially facet joint degeneration, is a risk factor for non-recovery after whiplash trauma.”

•••

The references above indicate three things:

• Degenerative spinal disease is ubiquitous in older persons, especially those >60 years of age.
• Degenerative spinal disease is often asymptomatic until exposed to injury.
• Pre-injury degenerative spinal disease, even if asymptomatic prior to injurious event, is a significant factor associated with a poor prognosis for recovery.

These concepts were thoroughly assessed in 2016, in a study that was published in the Annals of Emergency Medicine, titled (23):

Persistent Pain Among Older Adults Discharged Home
from the Emergency Department After Motor Vehicle Crash:
A Prospective Cohort Study

These authors described the incidence, risk factors, and consequences of persistent pain among 161 older adults evaluated in the emergency department (ED) after a motor vehicle crash. It is a prospective study of patients aged 65 years or older. Persistent pain and functional decline were reassessed at 6 weeks, 6 months, and 1 year after the accident.

At the 6-month evaluation, 26% of the subjects reported moderate to severe motor vehicle crash–related pain. This pain interfered with their general activities, including walking, sleep, and enjoyment of life; 23% of the subjects with persistent moderate to severe pain at 6 months had experienced a change in living situation to obtain additional help with their activities of daily living. The most common sites of pain at 6 months were lower back (25%), upper back (17%), and neck (17%).

More than half of the subjects (54%) continued to receive an analgesic (ie, an opioid, acetaminophen, or a nonsteroidal anti-inflammatory drug), and 18% were receiving a daily opioid, 10% of the subjects had become long-term opioid users.

These subjects showed very little improvement in the 1-year evaluation, indicating that most of the chronic problems at 6 months remained chronic at 12 months.

The authors noted:

“Older adults are an important subgroup of individuals experiencing a motor vehicle crash because safe and effective pharmacologic management of their acute pain is challenging, and once pain becomes persistent in older adults, it has profound negative consequences for function and quality of life.”

“Increased age has been identified as a risk factor for persistent motor vehicle crash–related pain.”

“Among older adults discharged home from the emergency department post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.”

“Our results add to the growing body of evidence that acute injuries in older adults can have a substantial negative effect on important long-term pain and health outcomes and extend these findings to a population of independently living older adults whom most clinicians would regard as lacking injuries likely to have long-term consequences.”

“The problem of persistent pain after a motor vehicle crash in older adults is not just a problem of persistent neck pain.”

“Persistent pain is an important determinant of functional decline among older adults experiencing a motor vehicle crash.”

“In this prospective multicenter study, we found high rates of persistent pain and associated disability among older adults discharged home from the emergency department after experiencing a motor vehicle crash.”

“These findings add to the increasing body of evidence of the clinical importance of seemingly minor injuries among older adults.”

“Even minor injuries can produce lasting effects, particularly in the elderly.”

“Emergency physicians should be aware that a substantial number of older patients with minor injuries are at risk for chronic pain.”

•••

It is essentially ubiquitous, older adults, especially for those aged >65 years, have degenerative spinal disease. Often, their spinal degenerative disease is asymptomatic, but “lit-up” when exposed to the forces of a motor vehicle collision. Pre-existing degenerative spinal disease renders those joints less capable of adequately handling and dispersing the forces of a new whiplash injury; therefore, injury to these joints and the surrounding soft tissues is greater; the amount of treatment required for maximum improvement is greater, and there are more long-term subjective, objective, and functional residuals.

REFERENCES

1. Garstang SV, Stitik TP; Osteoarthritis: Epidemiology, Risk Factors, and Pathophysiology; American Journal of Physical Medicine and Rehabilitation; November 2006; Vol. 85; No. 11; pp. S2-S11.
2. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG; Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations; American Journal of Neuroradiology (AJNR); April 2015; Vol. 36; No. 4; pp. 811–816.
3. Jackson R; The Positive Findings in Neck Injuries; American Journal of Orthopedics; August-September 1964; pp. 178-187.
4. Turek S; Orthopaedics Principles and their Applications; Lippincott; 1977; p. 740.
5. Cailliet R; Neck and Arm Pain; F. A. Davis Company; 1981; p. 103.
6. Norris SH, Watt I; The Prognosis of Neck Injuries Resulting from Rear-end Vehicle Collisions; The Journal of Bone and Joint Surgery (British); November 1983; Vol. 65-B; No. 5; pp. 608-611.
7. Webb; Whiplash: Mechanisms and Patterns of Tissue Injury; Journal of the Australian Chiropractors’ Association; June 1985.
8. Ameis A; Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury; Canadian Family Physician; September 1986; Vol. 32; pp. 1871-1876.
9. Dunn EJ, Blazar S; Soft-tissue Injuries of the Lower Cervical Spine; Instructional Course Lectures; 1987;Vol. 36; pp. 499-512.
10. Maimaris C, Barnes MR, Allen MJ; ‘Whiplash injuries’ of the neck: A retrospective study; Injury; November 1988; Vol. 19; No. 6; pp. 393-396.
11. Hirsch SA, Hirsch PJ, Hiramoto H, Weiss A; Whiplash syndrome: Fact or fiction? Orthopedics Clinics of North America; October 1988; Vol. 19; No. 4; pp. 791-795.
12. Foreman S and Croft A; Whiplash Injuries, The Acceleration/Deceleration Syndrome; Williams & Wilkins; 1988; p. 389, p. 395.
13. Porter KM; Neck Sprains After Car Accidents; British Medical Journal; April 15, 1989; Vol. 298(6679); pp. 973-974.
14. Watkinson A, Gargan M, Bannister G; Prognostic Factors in Soft Tissue Injuries of the Cervical Spine; Injury: the British Journal of Accident Surgery; July 1991; pp. 307-309.
15. Friedmann L, Marin E, Padula P; “Biomechanics of Cervical Trauma” in Painful Cervical Trauma, Diagnosis and Rehabilitative Treatment of Neuromusculoskeletal Injuries; Edited by C. David Tollison and John R. Satterthwaite; Williams and Wilkins; 1991, p. 17.
16. Schofferman J, Wasserman S; Successful treatment of low back pain and neck pain after a motor vehicle accident despite litigation; Spine; May 1, 1994; Vol. 19; No. 9; pp. 1007-1010.
17. Squires B, Gargan M, Bannister G; Soft-tissue Injuries of the Cervical Spine, 15-year Follow-up; Journal of Bone and Joint Surgery (British); November 1996; Vol. 78-B; No. 6; pp. 955-7.
18. Swerdlow B; Whiplash and Related Headaches; CRC press; 1999; p. 1040.
19. Malanga G, Nadler S; Whiplash; Hanley & Belfus; 2002; p. 91.
20. Schenardi C; Whiplash Injury, TOS and double crush syndrome, Forensic medical aspects; Acta Neurochirurgica; supplement, Vol. 92; 2005; pp. 25-27.
21. Nordhoff L; Motor Vehicle Collision Injuries, Biomechanics, Diagnosis, and Management; Second Edition; Jones and Bartlett; 2005, pp. 537-538.
22. Rydman E, Kasina P, Ponzer S, Jarnbert-Pettersson H; Association Between Cervical Degeneration and Self-perceived Non-recovery After Whiplash Injury; The Spine Journal; December 2019; Vol. 19; No. 12; pp. 1986−1994.
23. Platts-Mills TF, Flannigan SA, Bortsov AV, Smith S, Domeier RM, Swor RA, Hendry PL, Peak DA, Rathlev NK, Jones JS, Lee DC, Keefe FJ, Sloane PD, McLean SA; Persistent Pain Among Older Adults Discharged Home From the Emergency Department After Motor Vehicle Crash: A Prospective Cohort Study; Annals of Emergency Medicine; February 2016; Vol. 67; No. 2; pp. 166-176.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust^® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”