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  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 . 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 .
Treatment in acute whiplash can be delayed and confused by multiple social, economic, and psychological factors . 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 . 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. 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 .
8. WAD grade 2 or 3
9. No seat belt in use at time of collision
   

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 

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 education :

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 .

3. Advice according to The Whiplash Book :

• 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 soft collar .

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 .

EVIDENCE CONCERNING IMMOBILIZATION

AUTHOR	CONCLUSION	LEVEL
Quebec Task Force 1988	Prolonged immobilization may increase scar tissue in the neck and reduce cervical mobility	2B
Mealey et al 1986	Initial immobilization after whiplash injuries gave rise to prolonged symptoms. A more rapid improvement can be achieved by early active management without any consequent increase in discomfort	3A
Borchgrevink GE et al 2008	Advice to “act as usual” plus NSAIDs significantly improved some symptoms (including pain during daily activities, neck stiffness, memory, concentration, and headache) after 6 months compared with immobilisation plus 14 days' sick leave plus NSAIDs	1A
Teasell R.W. et al 2010	Immobilization with a soft collar is less effective than active mobilization and no more effective than advice to act as usual. Active mobilization is associated with reduced pain intensity and limited evidence that mobilization may also improve ROM, although it is not clear whether active mobilization is any more effective than advice to act as usual.	1A

EVIDENCE CONCERNING THE USE OF (SOFT) COLLAR

AUTHOR	CONCLUSION	LEVEL
Schnabel et al 2004	Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury	2B
Binder A. 2008	Instruction on mobilization exercises may be more effective than a soft collar at reducing pain at 6 weeks in people treated within 48 hours of a whiplash injury who all also took NSAIDs	1A
Schnabel M et al 2008	Exercises significantly reduce the proportion of people with neck pain at 6 weeks compared with a soft collar and significantly reduce pain and disability at 6 weeks	1A

EVIDENCE CONCERNING THE ADVICE TO “ACT AS NORMAL”

AUTHOR	CONCLUSION	LEVEL
Binder A 2008	Advice to "act as usual" plus NSAIDs may be more effective at 6 months than immobilization plus 14 days sick leave plus NSAIDs at improving neck stiffness in people with acute whiplash	1A
Borchgrevink GE et al 2008	Advice to “act as usual” plus NSAIDs significantly improved some symptoms (including pain during daily activities, neck stiffness, memory, concentration, and headache) after 6 months compared with immobilisation plus 14 days' sick leave plus NSAIDs	1A
Yadla S et al 2008	Early mobilization and return to activity may offer the best chance for recovery.	1A
Teasell R.W. et al 2010	It does not appear that providing educational information during the acute phase provides a significant measurable benefit. There is some indication that oral and/or video presentation of educational information may be more effective than the distribution of pamphlets.	1A

EVIDENCE CONCERNING PHYSICAL THERAPY

AUTHOR	CONCLUSION	LEVEL
Verhagen AP 2008	Limited evidence that active and passive interventions seemed more effective than no treatment. Less convincing evidence about active interventions compared with passive ones	1A
Binder A 2008	Instruction on mobilization exercises may be more effective than a soft collar at reducing pain at 6 weeks in people treated within 48 hours of a whiplash injury who all also took NSAIDs	1A
Lamb S et al 2013	Physiotherapy is recommended by several clinical guidelines. Recommended treatments include manual therapy, exercise, advice, and recognition of anxiety and psychological problems	2A
Schnabel M et al 2008	Exercises significantly reduced the proportion of people with neck pain at 6 weeks compared with a soft collar and significantly reduced pain and disability at 6 weeks	1A
Scholten – Peeters G et al 2008	No significant difference between physiotherapy (exercise or mobilization) and usual care in pain intensity, headache, or work activities measured at 8, 12, 26, or 52 weeks	1A
Söderlund A 2008	No significant difference between a regular exercise regimen versus the same exercise regimen plus instructions in disability or pain after 3 or 6 months	1A
Binder A 2008	Multimodal treatment (postural training, psychological support, eye fixation exer- cises, and manual treatment) may be more effective at improving pain at 1 and 6 months in people with whiplash due to a road traffic accident in the previous 2 months	1A
Teasell R.W. et al 2010	Exercise programs are significantly more effective in reducing pain intensity over both the short and medium term. Conversely, supplemental exercise programs added to mobilization programs may not be any more beneficial than mobilization programs alone.	1A
Drescher K et al 2008	Moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders. No evidence exists to support the use of postural exercises for increasing neck range of motion. Conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders.	1A

Example physical therapy:http://www.physio-pedia.com/Manual_Therapy_and_Exercise_for_Neck_Pain:_Clinical_Treatment_Tool-kit

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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