Predicting Outcomes in Whiplash

Original Editor - Tarina van der Stockt

Top Contributors - Tarina van der Stockt, Tony Lowe, Habibu Salisu Badamasi, Jess Bell and Robin Tacchetti

Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur during sport (diving, snowboarding) and other types of falls. The impact may result in bony or soft-tissue injuries affecting the ligaments, muscles, and nerves and may lead to other clinical manifestations call whiplash associated disorders (WAD). [1] [2] WAD is a term used to describe a collection of symptoms following a whiplash injury. [3] WAD symptoms range from neck pain, stiffness and tenderness, to loss of motor function and mental as well as stress reactions. [3] Usually patients recovery within 3 months after a whiplash injury but ½ of the patients with acute WAD go on to develop chronic pain and or disability. [2] To learn more about WAD you can click on the following link: Whiplash Associated Disorders

Early identification of the individuals that might have long term pain and disability will help clinicians to spend the correct resources in prevention and treatment., [4] This subject is continually being researched and therapists should stay up to date with the current research on predicting factors. [4]

Factors that predict poor outcomes[edit | edit source]

High levels of initial pain and a high score on the neck disability index are considered the strongest predictors of pain and disability after 6 months. [4] Other strong predictors include cold hyperalgesia, older age, and acute post-traumatic stress. [5]

1. High level of initial pain[edit | edit source]

Level of pain on Visual Analogue Scale 5.5/10 is considered high [4] High levels of initial pain is considered a very strong predictor of poor outcome in the long term[2] [4]

2. Characteristics of pain[edit | edit source]

Presence of Neuropathic pain (listen to descriptors used by patient in history taking - burning, electrical, mind of its own, area extra tender to touch, Allodynia, mottled appearance to the skin) pain from nerve tissue

Neck Disability Index (NDI) [4]

  • 10-item questionnaire, filled out by the patient asking the patient to rate activities of dailing living for e.g. personal care, reading, driving, concentration, pain intensity, lifting, sleeping, recreation, and headache on a 0-5 scale indicating disability in these activities. [6]
  • Along with pain intensity it is considered a very strong predictor of poor outcome in terms of chronic pain and disability
  • greater than 14.5/100 [4]

3. Psychological factors[edit | edit source]

Catastrophization

  • “Catastrophizing refers to an exaggerated negative orientation toward noxious stimuli” [7]
  • It is considered multidimensional and consists of the following: [8]
    • Rumination - when a person can’t stop thinking about the pain, especially how much it hurts
    • Magnification - fearful thoughts that something serious might happen
    • Helplessness - a feeling that there is nothing that can be done to alleviate the pain
  • In general these patients have a negative mindset on pain. They have passive coping skills like lying down, drinking pain medication, and expecting the clinician to fix them. They sometimes even look ill.
  • “Most robust and reliable psychological predictor of pain experience” [1]
  • Pain Catastrophizing Scale is a 13-item questionnaire where patients can rate the frequency of certain thoughts and feelings when they experience pain. [1]
  • Catastrophizing is considered a significant risk factor [9]
  • When reducing catastrophization in a patient the patient (acute/chronic) will have a decrease in pain severity and in disability [9]

Fear of movement

  • TAMPTA scale of kinesiophobia (TSK) is a 17-item questionnaire. It measures fear (re)injury due to movement. The scores range from 17 to 68 and a score of 37 is considered high. [6]
  • Ask the patient what are they concerned about, what fears do they have. For e.g. do they think that their spine is fragile and can easily be damaged? What movements or exercises are they avoiding?

Post traumatic stress reaction

A combination of high levels of pain plus post traumatic stress are considered a high predictor of poor outcome after whiplash.

  • Occurs in about 25% of people who sustain a whiplash in a motor vehicle accident [10]
  • Characterized by 3 major symptom groups (clusters): [10]
    • Re-experiencing of symptoms - intrusive thoughts about the accident coming to mind during the day, nightmares
    • Symptom avoidance - social withdrawal, avoiding any stimulus or thoughts that remind of the accident
    • Hyper aroused state - hyper vigilant, jumpy, irritable, high respiration rate
  • Ask the patient how often do they think about the accident. Do they keep telling you about the accident?
  • Measured by the Impact of Events Scale (IES). It is a 15-item questionnaire and screens for post-traumatic stress as it measures the current subjective stress regarding the specific life event. [11]
  • The EIS was revised include questions about hyper-arousal. It is called the Impact of Events Scale - Revised (IES)-R and is a 22-item questionnaire. Link to the revised scale: (IES)-R
  • IES should only be done 6 weeks after the injury as it is normal to have these intrusive thoughts before that.

Perception of injustice has been shown as a predictor of long term disability and pain after a whiplash injury[10]

4. Physical factors[edit | edit source]

Widespread tenderness in areas not affected by the injury

  • front of the shins
  • widespread hypersensitivity - tested with blunt pressure [12]

Cold pain threshold alteration (hyperalgesia) - is associated with higher pain and disability 6 months after the whiplash. [5]

  • (touched by metal at 15-20 degrees C feels like burning)
  • if the cold pain threshold decreases with even 1 degree compared to normal then the person have a high chance of developing moderate/severe symptoms in the long term [5]
  • Considered a strong sensory predictor along with impaired sympathetic vasoconstriction [5]
  • Thermal hyperalgesia (heat/cold) is seen soon after the whiplash injury in those individuals who develop ongoing moderate to severe pain/disability [12]
  • Could be indicative of peripheral nerve damage[5], “changes in the central mediation of pain”[12], or changes in the sympathetic nervous system [12].

Positive Upper limb tension test 1 (ULTT1) or brachial plexus provocation test [12]

  • A positive or heightened reaction is seen soon after the whiplash injury in those individuals who develop ongoing moderate to severe pain/disability
  • In patients with chronic the WAD the presence of a decrease in bilateral elbow extension with this test is indicative of motor and sensory changes due to central sensitisation
  • For more information on this test follow the link to Neurodynamic Assessment


Additional factors to consider[edit | edit source]

Weaker predictors of risk - can help with the prognosis and intervention decision making but cause and effect cannot be shown [4]

  • Female sex -- robust risk predictor [4]
  • Report of low back pain with evaluation after the incident [4]

Poor predictors

  • Range of motion of the cervical spine and changes in neck muscle activation after whiplash is not considered a significant predictor of long term pain and disability. [2]
  • Accident parameters as recalled by the patient is not considered a predictor for recovery. This might change in the future with more data as technology in vehicles improve. [4]
  • Past medical history [4]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Spitzer WO. et al. (1995). Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management. Spine (Phila Pa 1976)., 20(8 Suppl), pp. 1-73.
  2. ↑ 2.0 2.1 2.2 2.3 Daenen L, Nijs J, Raadsen B, Roussel N, Cras P, Dankaerts W. Cervical motor dysfunction and its predictive value for long-term recovery in patients with acute whiplash-associated disorders: a systematic review. Journal of rehabilitation medicine. 2013 Feb 5;45(2):113-22. [Accessed 14 June 2018] Available from: http://www.ingentaconnect.com/contentone/mjl/sreh/2013/00000045/00000002/art00001?crawler=true&mimetype=application/pdf
  3. ↑ 3.0 3.1 Golbakhsh MR, Mirbolook G, Mirbolook AR, Noughani F, Siavashi B, Gholizadeh A. Effect of Mental and Behavioral Factors on Severity of Whiplash Injury Disability. [Accessed 14 June 2018] Available from: http://traumamon.portal.tools/71693.pdf
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Walton DM, MacDermid JC, Giorgianni AA, Mascarenhas JC, West SC, Zammit CA. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):31-43. [Accessed 14 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://www.jospt.org/doi/pdfplus/10.2519/jospt.2013.4507&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=z48iW5iCN8OOygTTnLfgDA&scisig=AAGBfm2vfvPVzZoOSqUFSR19jsevoaEIkQ
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R. Physical and psychological factors predict outcome following whiplash injury. Pain. 2005 Mar 1;114(1-2):141-8. [Accessed 14 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://www.academia.edu/download/46453352/Sterling_M_Jull_G_Vicenzino_B_et_al._Phy20160613-23878-ftxn8w.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=FI0iW9mYJo_-yQTEtJ-gCQ&scisig=AAGBfm3nqbcO77XbvxRcJiBocwgLwu5aGg
  6. ↑ 6.0 6.1 Cite error: Invalid <ref> tag; no text was provided for refs named :5
  7. ↑ Scott W, Wideman TH, Sullivan MJ. Clinically meaningful scores on pain catastrophizing before and after multidisciplinary rehabilitation: a prospective study of individuals with subacute pain after whiplash injury. The Clinical journal of pain. 2014 Mar 1;30(3):183-90. [Accessed 14 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://sullivan-painresearch.mcgill.ca/pdf/abstracts/2014/Scottetal2014.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=BZIiW6rcGpLWygT11bHQCQ&scisig=AAGBfm0IwFurhAKGQz_pvBETeDEzxtLb6A
  8. ↑ Sullivan MJ, Rodgers WM, Kirsch I. Catastrophizing, depression and expectancy for pain and emotional distress. Pain. 2001 Mar 1;91(1-2):147-54. [Accessed 15 June 2018] Available from: http://sullivan-painresearch.mcgill.ca/pdf/abstracts/sullivanmar2001.pdf
  9. ↑ 9.0 9.1 Cite error: Invalid <ref> tag; no text was provided for refs named :9”
  10. ↑ 10.0 10.1 10.2 Sullivan MJ, Thibault P, Simmonds MJ, Milioto M, Cantin AP, Velly AM. Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain. 2009 Oct 1;145(3):325-31. [Accessed 15 June 2018] Available from: http://www.academia.edu/download/43075568/Pain_perceived_injustice_and_the_persist20160225-28621-1vu0w2l.pdf
  11. ↑ Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?–A preliminary RCT. Pain. 2007 May 1;129(1-2):28-34. [Accessed 14 June 2018] Available from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.611.9615&rep=rep1&type=pdf
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain. 2003 Aug 1;104(3):509-17. [Accessed 15 June 2018] Available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=11&ved=0ahUKEwjmhuWX0dbbAhUCVK0KHVlgDRQQFghdMAo&url=https%3A%2F%2Fpdfs.semanticscholar.org%2F07ff%2F7e81af852a6dcba56b5dba0f3fc9dba724e5.pdf&usg=AOvVaw0fCGn5gYPGxrzb1aFIs9SX
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