Dr. Bernhard Kügelgen, M.D., is a renowned specialist in pain medicine with impressive expertise and a wide range of therapeutic treatments. His holistic approaches are designed to address the individual needs of his patients and develop a precisely tailored treatment plan in close collaboration with them. Dr. Kügelgen successfully treats a wide range of pain conditions, including chronic back pain, headaches, migraines, tension headaches, and neuropathic pain. His areas of expertise also include complex conditions such as CRPS (Sudeck’s disease), post-traumatic pain, fibromyalgia, and neuropsychological syndromes. In addition, he has extensive experience in treating neurological conditions such as multiple sclerosis, peripheral nerve damage, and the aftereffects of strokes.
In Koblenz, Dr. Kügelgen co-directs the Therapiezentrum Koblenz and the MVZ Koblenz together with physical therapist Cecilija Kügelgen. These facilities specialize in the treatment of patients with chronic pain conditions and neurological disorders and offer a comprehensive, seamless range of therapies and care services. The MVZ Koblenz also serves as the Regional Pain Center of the German Society for Pain Therapy (DGS) for Koblenz and the surrounding area, providing comprehensive outpatient care across five practices.
The Koblenz Therapy Center complements this offering with semi-inpatient rehabilitation and multimodal therapy concepts tailored individually to each patient. A multidisciplinary team of fifty staff members supports Dr. Kügelgen at both facilities to ensure the best possible care for pain patients. In doing so, Dr. Kügelgen and his team place particular emphasis on fostering patients’ self-reliance and developing holistic treatment approaches that take individual circumstances into account.
In addition to his specialization in pain medicine and specialized pain therapy, Dr. Kügelgen is also a board-certified specialist in neurology, psychiatry, and physical and rehabilitative medicine. He is also qualified in algesiology—the science of pain therapy—and manual medicine (chiropractic therapy). Before joining the practice in Koblenz, Dr. Kügelgen spent twenty years in leadership positions at various specialized clinics in Germany, gaining valuable experience as a senior physician and chief physician.
His expertise and passion for pain medicine are also reflected in his numerous publications and educational videos, in which he addresses topics such as neuroorthopedics, chronic pain conditions, and post-traumatic chronic pain. As a founding member of Neuroorthopedics Germany and the Federal Working Group on Chronic Lower Back Pain (BAcK), he actively contributes to the advancement of his field. Dr. Bernhard Kügelgen is deeply committed to providing the best possible care for his patients and, through his comprehensive expertise and innovative treatment approaches, offers them a significant improvement in their quality of life.
The editorial team of the Leading Medicine Guide spoke with Dr. Kügelgen, focusing on whiplash—an often underestimated condition.
Whiplash, often still referred to medically as cervical spine distortion, is a common injury typically caused by an abrupt acceleration and deceleration, such as occurs in car accidents. This sudden movement can lead to overstretching of the neck muscles, triggering a range of symptoms, including gradually increasing pain in the neck and shoulder area, headaches, and dizziness.
“Clinically, the most typical features are the usually delayed onset of symptoms and findings over several hours (‘latency’), as well as localized pain, hypertonicity of the neck muscles, and significantly restricted and painful active and passive movement of the head due to a dysfunction of the neck muscles. In addition to this temporal progression—which is completely atypical for a sprain—it is notable that serious injuries to the head and neck region do occur in Formula 1 racing—hence the Head and Neck Support System (HANS system)—but not whiplash. This phenomenon provides the key to understanding the clinical picture: In normally fit individuals, even a slight stretch of tense muscles—such as can occur during a rear-end collision despite the use of a headrest—triggers metabolic activation in these muscles. The rear-end collision is transmitted to the person involved via the seat, leading to a reflexive tensing of the neck muscles. Even a slight stretching of the reflexively tensed neck muscles is sufficient to trigger this. This passive head movement cannot be prevented even by a correctly adjusted headrest. This stretching, the subsequent metabolic activation, and the accompanying swelling explain the pain and restricted movement that such patients experience after a few hours. It usually subsides within a few days; this is a physiological process. In isolated cases, however—particularly in women with a slender neck and generally weaker musculature—this pain-induced reduced activity over a period of several days to, at most, 1 to 2 weeks, until this physiological change subsides, can lead to the development of muscular insufficiency. “After all, these neck muscles must stabilize the head for 16–18 hours a day, which requires an enormous amount of support,” explains Dr. Kügelgen, adding:
“Acute treatment usually involves a combination of pain management, physical therapy, and—in more severe cases—specific medical interventions, including rehabilitation. Over the long term, analgesic measures are not helpful (see S3 guideline LONTS); under the influence of analgesia, the muscles become increasingly overburdened, increasingly weak, shorten, and become hypertonic, while head mobility becomes progressively more limited. It is well known that such changes in the neck muscles can trigger a diverse clinical picture, ranging from visual disturbances, hearing impairments, tinnitus, and problems with chewing function to facial paresthesias and even neuropsychological disorders (also referred to in the international literature as “whiplash-associated disorder”). An understanding of the mechanisms and effects of whiplash is crucial for the effective treatment and rehabilitation of affected patients, which is accompanied by physical and psychological pain management and must be carried out without the use of anesthetics, as these are indicated only in justifiable exceptional cases starting from the 3rd month onward, it is indicated only in justifiable exceptional cases and, moreover, hinders or even prevents successful muscular rehabilitation. The term “distorsion”—sprain—was introduced in Germany primarily by Hellmut Erdmann, a surgeon and radiologist, who, however, understood it to mean an unclear collection of non-osseous soft-tissue changes—that is, not a “distorsion” in the strict sense, as such a distortion, for anatomical reasons, could occur only during dorsal hyperflexion.”
At the beginning of the conversation, Dr. Kügelgen notes that, particularly in the case of whiplash, there have likely been many inconsistencies in the past regarding the diagnosis of whiplash and its medical acceptance. This is because whiplash injuries often occur primarily after car accidents and are therefore frequently a matter for the respective insurance companies when it comes to compensation for pain and suffering and sick leave. And, controversially, a diagnosed whiplash injury has often not been recognized as such. Dr. Kügelgen has been studying the condition since the 1980s and explains: “There is a simple principle: whoever heals is right. Here, in close collaboration with the Rhineland-Palatinate Accident Insurance Fund—which, as a workers’ compensation association, closely monitors every individual case—we can report a 95% success rate in the treatment of whiplash. In principle, whiplash is a condition that responds well to treatment. Thanks to our success, even the Rhineland-Palatinate Accident Insurance Fund has developed a secondary prevention program, so that there are now hardly any chronic cases here. For us, one thing is very clear: “Whiplash can be completely cured.” A consultation with Dr. Kügelgen is therefore based on in-depth knowledge and a wealth of experience, which lends this consultation a special quality.
Whiplash often occurs after sudden movements of the head, such as those that can happen in car accidents, falls, or sports injuries.
“It’s important to note first that with whiplash, nothing is broken—it’s not a bone injury. Typically, whiplash occurs when the head is suddenly jerked forward and then backward—or vice versa—which leads to overstretching of the neck muscles that have tensed reflexively. And this is by far the most common injury in traffic accidents. And in the vast majority of cases, whiplash heals on its own. Only about 2–5% of patients experience persistent symptoms that do not go away on their own. The problem for these individuals is that they were discharged with a diagnosis of whiplash, a few painkillers, and (in the past) a neck brace. “I spoke out against this measure many years ago—it has virtually no stabilizing effect and hinders normal head movement, but it is pleasantly warm and also serves as a kind of symbolic gesture. Following widespread criticism, this is now widely recognized,” states Dr. Kügelgen.
The symptoms of whiplash can vary widely, but neck pain, limited head mobility, and reduced endurance of the neck muscles are the most common and characteristic symptoms. This pain can range from mild to severe and often worsens when the head is moved. Along with neck pain, stiffness in the neck may also occur, making it difficult to turn or tilt the head. “Patients describe feeling as though their head is about to fall off,” comments Dr. Kügelgen. Headaches are another common symptom of whiplash and can also vary from mild to severe. Some people also experience shoulder pain that can radiate from the neck into the shoulders or arms. “In addition, dizziness, visual disturbances, jaw discomfort, or nausea may occur, especially when moving the head or neck. Another possible symptom is tingling or numbness in the arms or hands. This is because the neck muscles play an important role in controlling movement, and a dysfunction of these muscles can lead to dizziness and nausea,” adds Dr. Kügelgen.
“Whiplash is also not a spinal injury. This can be determined by the fact that patients often don’t notice symptoms until hours after the accident. It’s possible that those affected were in the hospital, underwent an examination, and nothing was found. But once they get home, symptoms gradually set in after some time. This allows us to rule out the spine as the source of the problem, since it would cause immediate pain. The reason for the delayed pain lies in the gradual increase in metabolic activity following the stretching of tense muscles, as described above. The resulting swelling triggers pain and restricted movement. It is well known, particularly in sports medicine, that highly trained athletes—such as Formula 1 drivers—do not suffer from this phenomenon of metabolic activation, whereas everyone else does. When stretched while tense, older muscle molecules are broken down through metabolic activation, which is associated with gradually increasing swelling, pain, and restricted movement. The neck muscles are thus stretched while tense—and, incidentally, this doesn’t only happen in traffic. When subjected to such forces, the head is moved forward, backward, to the right, or to the left despite the tense neck muscles. That’s why the pain doesn’t set in until later,” explains Dr. Kügelgen regarding the specific characteristic of pain development in whiplash.
“What is always underestimated is the stabilizing capacity of the neck muscles. This applies in particular, for example, to tour bus drivers and those in desk jobs. Women are affected more frequently. As the condition becomes chronic, patients find it increasingly difficult to maintain constant postural control over a period of time—that is, to maintain a consistent posture—because the same muscles are required for this stabilizing function; consequently, they try to shift the load to different muscles by changing their posture. Therefore, what absolutely does not help in cases of chronic whiplash is immobilization (usually in combination with painkillers). This carries the risk of developing chronic pain after about four weeks. The muscles are then swollen and severely shortened. And there are patients who, at the end of their ordeal, even resort to taking opioids,” explains Dr. Kügelgen.
When diagnosing and evaluating whiplash, a comprehensive approach is crucial for accurately identifying the specific injuries in the neck region.
The process usually begins with a detailed medical history, during which the doctor asks the patient about the circumstances of the traumatic event. This medical history provides important clues for the subsequent diagnostic steps. “You have to ask the patient very precisely what happened. It doesn’t have to be a car accident that caused the whiplash; it could also have been a head impact resulting from other causes, such as during school sports. The medical history is followed by a thorough physical examination. During this examination, the neck and back are examined for signs of injury, such as pain, swelling, or restricted movement (active and passive). The doctor also assesses neck mobility and tests muscle strength. In addition, neurological tests are performed to assess the function of the nervous system. “Imaging is only performed if a bony injury to the spine is suspected. So-called degenerative changes are not relevant here!” cautions Dr. Kügelgen.
The treatment of whiplash injuries aims to alleviate symptoms, promote healing, restore the functionality of the neck muscles, and completely resolve the various associated symptoms.
Physical therapy plays a central role in the treatment of whiplash injuries. An individually tailored physical therapy program includes exercises to reduce inflammation, such as trigger point therapy; stretching to improve muscle length and thus mobility; strengthening of the neck muscles; and, above all, training in endurance and coordination. This also includes systematic break management during prolonged periods of sedentary work.
“‘Keep moving’—that’s the top priority. Movement is very important, even if it hurts, as long as there are no indications of contraindications (such as an unstable vertebral fracture). Instead of excessive caution and prolonged rest, a systematic rehabilitation program focused on performance—not on how one feels—should be initiated, one that emphasizes endurance and coordination—that is, harmony of movement—rather than an increase in strength. The muscles must be kept in good condition so that they do not shorten and remain sufficiently functional. Only then can chronic pain be prevented. When pain is acute, cold therapy (e.g., in the form of cool packs) can also help, and initially, occasional use of Level 1 analgesics (non-opioids) is permitted, but not before therapy sessions. Patients quickly learn physical and psychological pain management techniques, thereby developing the ability to manage their own pain. It is the consistent implementation of these three simple components that helps patients overcome and heal from whiplash. It is essential to prevent the neck muscles from becoming increasingly unable to provide support. The further the condition becomes chronic, the more difficult the road to recovery becomes. Some patients then take medication for years, perhaps have their neck “adjusted” once or twice a week, or receive treatment through local injections. These are all acute medical relief measures, but they do not permanently solve the problem. The problem is and remains the musculature. It must be brought out of its state of irritation, then stretched, and finally develop the necessary endurance and coordination. “Patients are given information on tension exercises to improve postural function, and they should perform these exercises as interval training, during which a physical therapist can guide them; the therapist should then also monitor and, if necessary, correct a short, appropriate daily exercise program with the patient,” explains Dr. Kügelgen, adding recommendations for prevention: “Appropriate early management is of the utmost importance for every patient with such a muscle dysfunction. From the very beginning, maintaining muscle length and postural stability must be the focus of all therapies.”
Manual medicine plays an important role in the entire discussion surrounding this clinical picture. Numerous observations confirm the effectiveness of manual medicine interventions, whether in the form of manipulation (with an impulse) or mobilization (without an impulse), which provide prompt relief of symptoms. There are numerous theories regarding which functional disorder underlies this successful therapy. Most likely, the muscle dysfunction described above is responsible for this as well, since such a manual therapy intervention always leads to a refractory phase in the regional musculature, which temporarily loses significant tone and, during this time, results in considerable relief of symptoms. However, such unquestionably successful manual medical treatments—like other pain-relieving measures—should only be used at the outset and on a few occasions; if symptoms persist, the underlying cause—specifically the muscle dysfunction—must be addressed. This “adjustment” only feels good because it triggers a reduction in muscle tone in the soft tissue segment. This is merely temporary relief lasting a few hours—which could also be achieved, for example, by injecting a painkiller—and is interpreted by the patient as a success.
In some cases, workers’ compensation agencies or civil courts may have difficulty appropriately assessing whiplash injuries.
Problems can arise when certain experts or outdated methods are used to assess the severity of the injury and the associated claims. One challenge is that whiplash injuries often involve subjective symptoms that are not easily measurable objectively. This sometimes leads to the credibility of those affected being called into question.
“In cases of whiplash, it is important to make the discussion more objective. The clinical picture must be fully understood. Education is urgently needed here! For lawyers and insurance companies, it ultimately always comes down to money, not the patient’s well-being. After all, whiplash remains the most common injury in traffic accidents. It is a serious methodological error to attempt to resolve a medical problem through legal or political means—or even through automotive experts—instead of allowing medical specialists to develop an appropriate and transparent solution,” says Dr. Kügelgen.
Now a word about the literature:
In 1995, the Quebec Task Force published a very comprehensive report. In a literature review of 10,036 publications, only 62 (= 0.6%!) methodologically sound and worthwhile studies were found, but even these were unable to solve the mystery. Over 90% of the literature deals with medical assessment. However, a medically unclear problem cannot be resolved through medical assessment.
This study classifies whiplash injury into different grades with corresponding recommendations; however, for the problematic groups 1 through 3, only a reevaluation is scheduled after 12 weeks. The authors themselves acknowledge that much work remains to be done to solve the mystery:
The gap in our knowledge regarding prevention, diagnosis, and rehabilitation is particularly noteworthy. ... Despite the paucity of scientific evidence, we redefined and formally classified WAD*.
*whiplash-associated disorder
Far too little attention has been paid to the fact that this is a very extensive study, but one based exclusively on insurance records. The study does not provide clear clinical diagnostic criteria for confirming or ruling out the condition. The same applies to the frequently cited study from Lithuania, which describes a correlation between the frequency of whiplash diagnoses and the insurance system. It is obvious that there is a connection between the development of the insurance system and the management of medical conditions. However, this does not alter the rules governing how a physician makes a diagnosis. Since this is also purely a chart-based study, its conclusions regarding the clinical picture are worthless.
From 1998 to 2013, an orthopedic surgeon in Germany—as, incidentally, in other countries as well—attempted, at the instigation of insurance companies, to rule out the clinically unclear clinical picture by examining the vehicles involved in an accident. This audacious approach, which contradicts all rules of clinical medicine, has made its way through the courts all the way to the Federal Court of Justice and has led to the establishment of approximately 500 automotive assessment centers in Germany alone that perform such evaluations on vehicles. However, there are rules governing when a clinical picture is to be identified or ruled out through instrumental diagnostics:
- Sensitivity (Are those who are actually sick correctly identified as sick?)
- Specificity (Are people who are actually healthy correctly identified as healthy?)
- Validity (Are we really measuring what we intend to measure?)
- Reliability (reproducibility of the measured values)
- Measurement error (range of variation, always to be specified).
This has never been done, since the actual clinical picture of the condition has never been clearly defined. Even more audacious is the attempt to prove that an injury such as whiplash can occur even in a simulated rear-end collision. These frequently cited publications have hardly been read; otherwise, the numerous methodological flaws would have been noticed. Furthermore, this injury does not occur exclusively in traffic accidents, where the speed difference is 0. It must be obvious that such a test, with its supposedly high diagnostic value, would then also have to be incorporated into standard clinical diagnostics outside the context of expert evaluations. To date, no university hospital performs this test. In 2013, the author was exposed by two German regional courts as an unreliable expert witness. “Ultimately, it would be very beneficial if doctors were to refocus on the diagnosis and treatment of this condition, and if expert witnesses were to follow the findings derived from that work, thereby convincing the courts through comprehensible expert reports,” Dr. Kügelgen makes very clear, and with that, we conclude our discussion on this highly controversial topic.
Thank you very much, Dr. Kügelgen, for this open and engaging conversation on the important clinical picture of whiplash!
References
Whiplash Injury—A Solvable Problem. Kügelgen, B. (2011). In: Kress, H. G. (Ed.), Current Pain Therapy—Standards and Developments. ecomed Medizin, Landsberg. Included therein: Consensus on Whiplash Injury
Distortion of the Cervical Spine. Kügelgen, B., ed. (1995). Neuroorthopedics 6. Springer, Heidelberg, New York
Schrader et al. (1996) Natural evaluation of late whiplash syndrome outside the medicolegal context. Lancet 347 (9010), 1207–1211
Spitzer, W. O., et al. (1995) Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders: Redefining “Whiplash” and Its Management. Spine 20: 1–73
