Sensible advice for aches, pains & injuries

A Recipe for Chronic Neck Pain After Whiplash

Researchers discover some surprising risk factors for chronic neck pain in the aftermath of whiplash

updated (first published 2009)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about

One of the strangest things about low back pain and neck pain is how much they seem to be affected not just by emotional factors, but even specifically by our confidence that we will recover. Some of the evidence for this is explained in detail in my full tutorials, especially the low back pain tutorial:

However, in this short article I zoom in on one significant 2006 study about neck pain. Note that what applies to neck pain probably also applies to low back pain.

It’s not just the accident, it’s how healthy you were when it happened

This idea has been around for a long time: your emotional and physical health before you have experience a trauma like a car accident has a lot do with with how much pain you are going to have afterwards. And that idea part of a more general belief in the power of prevention: that physical therapy is not just for rehab, but for reducing the need for it before an accident even happens.

This emphasis on pre-trauma health and the value of prevention has long been an iconic feature of physical therapies like massage and chiropractic, a bullet point in the sales pitch, a reason to pay for these services even when there’s nothing obviously wrong with you. That belief, once one of the symbols of how wisely alternative we were, is now increasingly mainstream, and increasingly based on hard scientific evidence.

Hundreds of car accident victims surveyed

In 2006, a UK research group at University College London studied people in the aftermath of whiplash accidents.1 They surveyed almost 500 people at three points — one, three, and twelve months after collision — asking them about their neck pain. It was no surprise that the worst whiplash injuries led to the worst pain later on. People with badly damaged neck muscles and ligaments were more likely to have chronic pain than people with less serious injuries, of course.

But the importance of injury severity, the obvious factor, was actually outweighed by much less obvious ones. The researchers concluded (my emphasis):

“The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself.”

That’s remarkable. Worth writing an article about. And, importantly, it has been backed up by other science since then.2

Health status before accidents isn’t just “a factor” in how well you recover… it’s huge!

It’s easy enough to see how your physical health going into an accident would have something to do with how well you recover, but the “psychological distress” part is weirder, and strangest of all is that both of these factors are actually a greater risk factor for chronic pain than the severity of your accident.

All other things being equal, a severe accident is going to hurt worse than a lesser accident … but your mental and physical health going into it actually trumps the severity of the accident as a predictor of long term neck pain. Wow.

So a person who has a severe accident with awful whiplash may actually recover quickly and have no chronic neck pain … if they have no history of body pain and minimal emotional stress. By contrast, someone who has a relatively minor accident may be worse off in a year … if they went into the accident with those psychological and physical risk factors.

Risk factors for chronic pain after whiplash have a cumulative effect

There’s another layer of newsworthiness here: Atherton et al found that a combination of pre-injury risk factors results in a disproportionate stubborn-ness of post-injury pain. Patients who had all of the measured risk factors were five times as likely to have persistent neck pain.

Misfortune begets misfortune!

This is such a grim finding that advice to avoid driving seems justified for anyone who has been under stress and already has a history of widespread body pain. The stakes are too high! It’s bad enough to have whiplash, but it’s devastating for whiplash to turn into severe chronic pain.

Driving is a dangerous, and it kills more people than any other common human activity by far. It often surprises me how readily we accept those risks. And the risks are clearly higher for some people that others.

“I told you so!”

Maybe the science isn’t surprising. Maybe it’s just filling in a blank. It’s just what almost any physical therapist, massage therapist, or chiropractor would have said about it — without the benefit of supporting evidence. This is a rare case of good evidence supporting a popular idea (it’s more common, I think, for experiments to turn “common sense” on its head).

Ironically, even now that the evidence is available, I doubt many professionals are actually aware of it!

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

Revised for clarity and thoroughness. Added more recent scientific review, adding support to the original citation the article is based on. New, more descriptive headings.


  1. Atherton K, Wiles NJ, Lecky FE, et al. Predictors of persistent neck pain after whiplash injury. Emerg Med J. 2006 Mar;23(3):195–201. PubMed #16498156. PainSci #56091. BACK TO TEXT
  2. Carstensen TB. The influence of psychosocial factors on recovery following acute whiplash trauma. Dan Med J. 2012 Dec;59(12):B4560. PubMed #23290295. BACK TO TEXT