Whiplash Associated Disorders

Original Editor - Hannah Norton

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Clinically Relevant Anatomy

Whiplash and whiplash associated disorders (WAD) affects variable areas of the cervical spine, depending on the force and direction of impact as well as many other factors. In a whiplash injury, bony structures, ligamentous structures, muscles, neurological structures, and other connective tissue may be affected. Anatomic causes of pain can be any of these structures, with the strain injury resulting in secondary edema, hemorrhage, and inflammation.

Mechanism of Injury / Pathological Process

The mechanism of injury is variable, usually involving a motor vehicle accident but also including causes such as sports injury, child abuse, blows to the head from a falling object, or similar accelleration-decceleration event.

Clinical Presentation

The most common presentation will be sub-occipital headaches and/or neck pain that is constant or motion-induced. There may be up to 48 hrs delay of symptom onset from the initial injury. Other signs include neurologic signs, dizziness, tinnitus, visual disturbances, UE radicular pain, difficulty sleeping due to pain, and difficulty concentrating/poor memory. (eMedicine) It is important to provide a thorough spinal exam and neurologic exam in patient with WAD to screen for delayed-onset of cervical spine instability or myelopathy.

QTFC (Quebec Task Force Classification)

The Quebec Task Force was a task force sponsored by a public insurer in Canada.  They submitted recommendations regarding classification and treatment of WAD, which was used to develop a guide for managing whiplash in 1995.  An updated report was published in 2001.  Each of the grades corresponds to a specific treatment recommendation.

QTFC Grade	Clinical presentation
0	No complaint about neck pain No physical signs
I	Nec complaints of pain, stiffness or tenderness only No physical signs
II	Neck complaint Musculoskeletal signs including decreased ROM point tenderness
III	Neck complaint Musculosceletal signs Neurological signs including: decreased or absent deep tendon reflexes muscle weakness sensory deficits
IV	Neck complaint and fracture or dislocation

MQTFC (Modified Quebec Task Force Classification)

Proposed classification grade	Physical and psychological impairments present
WAD 0	No complaints about neck pain No physical signs
WAD I	No complaints of pain, stiffness or tenderness only No physical signs
WAD IIA	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) Sensory Impairment local cervical mechanical hyperalgesia
WAD IIB	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) Sensory Impairment local cervical mechanical hyperalgesia Psychological impairment elevated psychological distress (GHQ, TAMPA)
WAD IIC	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) increased JPE Sensory Impairment local cervical mechanical hyperalgesia generalized sensory hypersensitivity (mechanical, thermal, ULNT) Some may show SNS disturbances Psychological impairment elevated psychological distress (GHQ, TAMPA) elevated levels of acute posttraumatic stress (IES)
WAD III	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) increased JPE Sensory Impairment local cervical mechanical hyperalgesia generalized sensory hypersensitivity (mechanical, thermal, ULNT) Some may show SNS disturbances Neurological signs of conduction loss including: decrease or absent deep tendon reflexes muscle weakness sensory deficits Psychological impairment elevated psychological distress (GHQ, TAMPA) elevated levels of acute posttraumatic stress (IES)
WAD IV	Fracture or dislocation

Diagnostic Procedures

Canadian C-Spine Rule (CCR): algorithm to determine the necessity for cervical spine radiography in alert and stable patients presenting with trauma and cervical spine injury.

Canadian C-Spine Rule

Management / Interventions

Management approaches for patients with WAD are poorly researched. These patients often do not fit into treatment categories as defined for other cervical pain problems due to multiple factors, and even within the WAD group there are multiple variances which warrant individualized treatment approaches. The most recent evidence supports the use of Sterling's classification system for WAD.  

ACUTE WHPLASH

Whiplash – associated disorder (WAD) is a debilitating and costly condition of at least 6-month duration. Although the majority of patients with whiplash show no physical signs 1 studies have shown that as many as 50% of victims of whiplash injury (grade 1 or 2 WAD) will still be experiencing chronic neck pain and disability six months later ². In most cases, symptoms are short lived, but a substantial minority go on to develop LWS (late whiplash syndrome), i.e. persistence of significant symptoms beyond 6 months after injury 3.
Treatment in acute whiplash can be delayed and confused by multiple social, economic, and psychological factors 4. Psychological factors such as depression, anxiety, expectations for recovery, and high psychological distress have been identified as important prognostic factors for WAD patients. Coping strategies such as diverting attention and increasing activity are related with positive outcomes 1. In order to avoid chronicity, it is important to screen for prognostic factors in time. According to Walton et al, there are 9 significant predictors 1:

1. No postsecondary education
2. Female gender
3. History of previous neck pain
4. Baseline neck pain intensity above 55/100
5. Presence of neck pain at baseline
6. Presence of headache at baseline
7. Catastrophizing: there is evidence of catastrophizing and reinterpreting pain sensations being maladaptive for patients exposed to whiplash trauma 14.
8. WAD grade 2 or 3
9. No seat belt in use at time of collision 1

Education provided by physiotherapist or general practitioner is important in prevention of chronic whiplash. The most important goals of the interventions are:

1. Reassuring the patient
2. Modulating maladaptive cognitions about WAD
3. Activating the patient 1

There is strong evidence for most forms of verbal education for whiplash patients in order to reduce pain, enhance neck mobility, and improve outcome. In acute patients oral information is equally efficacious as an active exercise program. In acute whiplash patients, a short oral education session is effective in reducing pain and enhancing mobility and recovery. Different types of education1:

1. Oral Education: there is strong evidence for providing oral education concerning the whiplash mechanisms and emphasizing physical activity and correct posture. It has better effect on pain, cervical mobility, and recovery, compared to rest and neck collars. Furthermore oral education would be as effective as active physiotherapy and mobilization.

2. Psycho – educational video: A brief psycho-educational video at bedside seems to have a profound effect on subsequent pain and medical utilization in acute whiplash patients, compared to the usual care 1.

3. Advice according to The Whiplash Book ³:

• Reassurance that prognosis following a whiplash injury is good.
• Encouragement to return to normal activities as soon as possible using exercises to facilitate recovery
• Reassurance that pain is normal following a whiplash injury and patients should use analgesia consistently to control this
• Advice against using a collar ³.

Conclusions of the Cochrane review (Gross A., et al., Patient education for neck pain 2012):
With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Differential Diagnosis

Cervical radiculopathy
Facticious disorder
Polymyalgia Rheumatica
Traumatic Brain Injury
Cervical herniated disk
Cervical myelopathy
Cervical osteoarthritis
Infection or osteomyelitis
Inflammatory rheumatologic disease
Malingering
Psychogenic pain disorder
Referred pain from cardiothoracic structures
Tumor or malignancy of cervical spine

Vascular abnormality of cervical structures

Key Evidence

"Whiplash associated disorders- redefining whiplash and its management" by the Quebec Task Force: a critical evaluation.

Resources

www.som.uq.edu.au/whiplash

Evidence-based summary

Case Studies

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Recent Related Research (from Pubmed)

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References

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