Whiplash Associated Disorders

Definition/Description

Whiplash-associated disease (WAD) is the term used to describe injuries sustained as a result of sudden acceleration-deceleration movements. It is considered the most common result after a non-catastrophic motor vehicle accident. [1] The term WAD is often used synonymously with the term Whiplash However, whiplash refers to the mechanism of injury rather than the symptoms that occur in the absence of injury or structural pathology, such as pain, stiffness, muscle cramps, and headache. [2][3] The prognosis of WAD is unknown and unpredictable, some cases remain severe, but full recovery Some progression of chronic pain and disability [3] Early intervention recommendations are rest pain relief and basic stretching. [3]

The short video below sums up WAD nicely

[4]

Clinically Relevant Anatomy

Whiplash and whiplash-associated disease (WAD) affect various anatomical structures of the cervical spine, depending on the force and direction of the impact, as well as many other factors [5][6][7]. Pain may be due to any of these tissues, secondary edema due to strain Bleeding and inflammation:

• Joints: facet joint, atlantoaxial joint, atlanto-occipital joint
• Intervertebral discs and cartilage endplates
• muscles
• Ligaments: Alar ligament Anterior atlantoaxial ligament Atlantooccipital anterior ligament Parietal ligament Anterior longitudinal ligament Transverse atlantoaxial ligament
• Bones: Atlas axis vertebrae (C3-C7)
• Nervous System Structures: Nerve Roots Spinal Cord Brain Sympathetic Nervous System
• Vascular structures: internal carotid and vertebral arteries
• Adjacent joints: Temporomandibular joint Thoracic rib shoulder complex
• peripheral vestibular system

Pathology

Most WADs are considered to be minor injuries based on soft tissue without evidence of fracture.

Injury occurs in three stages:

• Phase 1: The upper and lower spine undergoes flexion in Phase 1
• Stage 2: The spine takes an S shape, begins to stretch and eventually straightens, bringing the neck forward again.
• Stage 3: Shows extension of the entire spine, with strong shear forces causing compression of the facet joint capsules.

Studies of cadavers have shown that whiplash is the development of an S-shaped curvature of the cervical spine, resulting in hyperextension of the lower spine and curvature of the upper spine beyond the physiological limits of spinal mobility.

The Quebec Task Force categorizes WAD (whiplash) patients according to the severity of signs and symptoms as follows:

1. Grade 1 patients complain of neck pain, stiffness, or tenderness but no positive findings on physical examination.
2. Grade 2 patients exhibit musculoskeletal symptoms, including reduced range of motion and tender points.
3. Grade 3 patients also present with neurologic signs, which may include sensory deficits, decreased deep tendon reflexes, and muscle weakness.
4. Grade 4 patients showed fractures [8].

Etiology

Whiplash-associated disorders describe a range of clinical symptoms associated with the neck following MVA or acceleration-deceleration injuries. The pathophysiology supporting this disease is still not fully understood and many theories exist. Some symptoms are thought to be caused by physical injury The following structure:

• Cervical Spine Facet Joint Capsule
• The facet joints
• Spinal ligaments
• Nerve roots
• Intervertebral discs
• Cartilage
• Paraspinal muscles causing spasms
• Intraarticular meniscus.[8]

Epidemiology

The most common cause of WAD is MVA, but it can also occur from sports injuries and falls. A study by Holm et al. showed that the number of people reporting symptoms has increased in recent years; in their 2008 paper, they proposed that North American and Approximately 300 per 100,000 inhabitants in Europe [9]. In the United Kingdom, mandatory seat belt wearing was introduced in 1983 to save road deaths and actually led to an increase in the number of WADs reported over the years [10]. It’s also more common in women than men Two-thirds of women experience symptoms, and multiple studies have found that recovery tends to be slower or incomplete in women compared with men [11].

The risk of WAD in post-accident patients with cervical energy transfer acceleration and deceleration mechanisms depends on several factors:

• The severity of the impact however is difficult to obtain objective evidence to substantiate this [12].
• Pre-accident neck pain is a risk factor for acute neck pain after a collision [13].
• Women appear to be more likely to develop WAD.
• Age is also important; younger adults (18-23) are more likely to make insurance claims and/or are at greater risk for WAD treatment [14][15].

The number of people suffering from chronic pain worldwide ranges from 2% to 58%, but mostly between 20% and 40% [13].

• If patients are still symptomatic 3 months after the accident, they are likely to persist for at least two years and possibly longer [15].
• 50% of whiplash victims recover fully
• 25% may have mild disability, the remainder have moderate to severe pain and disability[16]

There are many prognostic factors that determine the evolution of WAD and its likelihood of developing into chronic pain.

• Unfavorable expectations for resuming passive coping strategies and posttraumatic stress symptoms have been found to be associated with chronic neck pain and/or disability after whiplash [17]
• Self-reported unexplained pain before crash High psychological stress and low education level in females predict future self-reported neck pain [18].
• Past history of neck pain Neck pain intensity greater than 55/100 at baseline Neck pain present at baseline Catastrophic WAD grade 2 or 3 headache at baseline and not wearing a seatbelt at the time of the collision [19].[16]
• If the patient was unemployed or had social assistance before the accident [18].
• Baseline disability is strongly associated with chronic disability, but psychological and behavioral factors are also important [20].
• Cold Pain Threshold Neck ROM Headache Posttraumatic Stress Symptoms Hyperactivity Symptoms (PDS) Initial High Neck Disability Index (NDI)[16]

Whiplash Clinical Prediction Rule

The Clinical Prediction Rule (CPR) is a tool that helps predict outcomes such as a person’s likelihood of moderate/severe pain and disability or full recovery following a whiplash injury. [16] CPR is primarily used in the following situations:[16]

• Complex decision-making
• Uncertainty
• Potential for cost savings without compromising patient care

CPR recommendations for WAD are as follows:[16]

• Probability of chronic moderate/severe disability, older age (≥35), initial high level of neck disability (NDI ≥40) and symptoms of hyperactivity
• Likelihood of full recovery at younger age (≤35) and with initial low-level neck disability (NDI≤32)

Clinical Prediction Rule Algorithm

Ritchie et al found that this type of CPR was reproducible and accurate when used after whiplash injury from a motor vehicle collision [21] Kelly et al explored the agreement between physical therapists’ prognostic risk classification and whiplash CPR The consistency is found to be very low. Physiotherapists are often overly optimistic about patient outcomes. Therefore, Kelly et al suggested that CPR may be beneficial to physical therapists when evaluating patients with whiplash injuries. [twenty two]

Clinical Presentation

Whiplash-related disorder is a complex disorder with various impairments in motor-sensory-motor and sensory functions, and associated psychological distress [23][24]. The most common symptoms are persistent or exercise-induced suboccipital headache and/or neck pain [25]. May be delayed up to 48 hours Symptoms develop from the initial injury [26].

Motor Dysfunction

• The range of motion of the cervical spine is limited. [5][23].
• Altered muscle recruitment patterns in the cervical spine and shoulder girdle region (apparently a feature of chronic WAD) [23][27][28][29].
• Mechanical cervical instability [26]

Sensorimotor dysfunction (more severe in patients who also reported dizziness due to neck pain [23][30][31][32])

• Loss of balance
• Neck discomfort affecting eye movement control [26]

Sensory dysfunction: Hyperesthesia to various stimuli

• Psychological distress
• Post-traumatic stress[23]
• Concentration and memory problems [30][31][33]
• Sleep disturbances[34]
• Anxiety[30]
• Depression[30]
  • Initial depression: Associated with greater neck and lower back pain Severe arm/hand numbness/tingling Vision problems Dizziness Fractures [35]
  • Persistent depression: associated with older age Worse initial neck and lower back pain Post-crash dizziness Anxiety Numbness/tingling Vision and hearing problems [35]

Degeneration of Cervical Muscles

• Neck stiffness[30][31]
• Fatty infiltration may be present in the deep muscles of the suboccipital region, and the multifidus muscle may lead to some dysfunctions, such as: proprioceptive deficits loss of balance loss of neck motor control impairment [36] [25] [27] [28] [30][ 29][31]

Other Symptoms

The following symptoms may also be present [26][30]

• Tinnitus
• Malaise
• Disequilibrium/Dizziness
• Thoracic temporomandibular and extremity pain

It is important to perform a thorough spinal and neurologic examination in patients with WAD to screen for delayed onset cervical instability or myelopathy [26]. Whiplash can be an acute or chronic condition. Acute whiplash lasts no longer than 2-3 months, whereas chronic Whipping symptoms persist for more than three months. Pressure hypersensitivity and decreased mobility of the cervical spine are common in patients with acute WAD [37]. Various studies have shown that spontaneous recovery can occur within 2-3 months [38] According to the WAD Quebec Task Force (QTF-WAD) 85% of patients recovered within 6 months [39].

Furthermore, according to a follow-up study by Crutebo et al. (2010) Some symptoms were already transient at baseline, and symptoms such as neck pain further reduced cervical range of motion, headache, and low back pain over a 6-month period. they also investigated depression, and found that at baseline, this was approximately 5% in both women and men, while post-traumatic stress and anxiety were more common in women (19.7% and 8.6%, respectively) than men (13.2% and 8.6%) 11.7%). Most reported associated symptoms were mild at baseline and during Follow-up [40].

Evaluation

The Canadian Cervical Spine Rules or NEXUS criteria are useful for the evaluation of cervical spine injuries in the emergency department. These criteria determine the need for imaging based on the mechanism of physical manifestations of the injury at the time of the accident symptoms Emergency department and physical examination.

• The NEXUS c spine criteria recommend imaging in the presence of cervical posterior midline tenderness, focal deficits, altered mental status, intoxication, or distraction impairment.
• Canadian c spine rules define the necessity of imaging in patients over 65 years of age Hazard Mechanism of injury Paresthesia Midline tenderness Immediate onset neck pain and impaired range of motion.

For abnormal findings on CT, additional imaging, such as MRI, may be needed to evaluate for spinal cord injury. Flexion and extension films help rule out ligamentous injury [8]

Clinical Diagnosis

WAD can be diagnosed based on the mechanism of injury and the patient’s clinical presentation [27] [41]. There are no specific neuropsychological tests that can diagnose WAD [41]. However, as mentioned above, there are several psychological symptoms associated with WAD. another one Whiplash-like high scores have been developed on subscales of somatized depression and obsessive-compulsive behavior in WAD patients [14].

Differential Diagnosis

Includes:

• Cervical spine fracture,
• Carotid artery dissection,
• Herniated disc,
• Spinal cord injury,
• Subluxation of the cervical spine,
• Muscle strain,
• Facet injury,
• Ligamentous injury. 

Outcome Measures

• Neck Disability Index[39][42][43][43]
• Visual Analogue Scale (VAS)[39][43]
• Pain Catastrophizing Scale
• Whiplash Active Attendance List (WAL)[44]
• Disability of the arm, shoulder and hand in sustained whipping (DASH) [45]
• SF-36[46][43]
• Functional Rating Index[43]
• The Self-Efficacy Scale[43]
• The Coping Strategies Questionnaire[43]
• Patient-Specific Functional Scale[43]
• General Health Questionnaire (CHQ)

Examination

Evaluation of patients with WAD should follow normal cervical examination.

Subjective

The subjective medical history should specifically include the following information:

• Past history of neck problems (including previous whiplash)
• Past history of long-term problems (injuries and illnesses)
• Current psychosocial issues (finance related to home work)
• Symptoms (location + time of onset)
• Mechanism of injury (eg, sport vehicle)

Objective

A physical examination is required to identify symptoms and signs and to classify WAD according to the QTF-WAD [47].

Inspection and Palpation

During palpation, muscle stiffness and tenderness can be observed. These physical symptoms appear in grades 1, 2 and 3. Trigger points may also be observed in grade 2 and grade 3 WAD. Number of active trigger points may be linked to higher neck pain intensity Accidents lead to hyperalgesic pain hypersensitivity in the cervical spine and decreased active cervical range of motion [37].

ROM Testing

There were no signs in grade 1 WAD, so ROM was not reduced. In grades 2 and 3, ROM reduction can be identified by testing neck flexion-extension-rotation and 3D motion [37] [47].

Neurological Examination

To distinguish grade 3 from grade 2, a neurological examination is required. Grade 3 patients present with symptoms of hypersensitivity to various irritants. These can be subjectively reported by the patient and may include allodynia, hyperirritability to pain, sensitivity to cold, and poor sleep due to pain.

Objectively, the findings of the neurological examination were hyporeflexic decreased muscle strength and sensory deficits of the dermatotomy and myotomy. These reactions may occur independently of psychological distress. Other physical tests for hypersensitivity include barometric pain and Ice or increase bilateral responses to brachial plexus provocation tests.

Management

• Education and mobilization exercises to return to normal activities are usually the treatment of choice.
• Ultrasound has also been shown to relieve muscle pain in whiplash-related disorders.
• First-line treatment includes analgesics, NSAIDs, ice, and heat.
• Other controversial pain-relieving measures include muscle relaxants, which have shown some therapeutic benefit in limited studies.
• Biofeedback has also been shown to be effective when used in combination with other modalities in acute WAD.
• Intramuscular injections of lidocaine have also been found to relieve painful symptoms.
• Most treatments alone appear to be moderately effective, with a combination of measures to enhance efficacy and early mobilization consistently most effective [8]

Physical Management

A major pillar of acute WAD management is providing advice to encourage return to usual activities and exercise, an approach advocated in current clinical guidelines. [47]

• Management approaches for patients with WAD have been poorly studied.
• Due to multiple factors and multiple differences, patients often do not fit into treatment classes, which requires an individualized approach to treatment [28].
• Whiplash-related illness is a debilitating and costly illness that lasts at least 6 months.
• Most whiplash patients are asymptomatic [48], but up to 50% of victims of WAD grades 1 and 2 will still experience chronic neck pain and disability after 6 months. A significant proportion of people develop LWS (Late Whiplash Syndrome), where significant symptoms persist More than 6 months after injury [49].
• The combination of injury and psychological factors, such as poor coping styles, may lead to chronic WAD [50].

Acute Whiplash

Education provided by a physiotherapist or general practitioner is important to prevent chronic whiplash and must be part of a biopsychosocial approach to the whiplash patient. The most important goals of the intervention are to:

1. Reassuring the patient
2. Modulating Maladaptive Perceptions of WAD
3. Activating the patient[48]

• The goals of education are to remove barriers to treatment, improve treatment adherence, and prevent and treat chronicity [48].
• Verbal education and written counseling are helpful for acute WAD (evidence shows that verbal messages are as effective as an aggressive exercise program) [48].
• A multidisciplinary program is best suited for subacute/chronic patients, with a program that integrates informational exercises and behavioral programming.

Different types of education include [48]:

1. Oral Education: Provide oral education on the mechanics of whipping, emphasizing physical activity and proper posture. It has a better effect on painful cervical mobility and recovery than rest and a cervical collar. Oral language education may be as effective as aggressive physical therapy mobilization.
2. Educational videos: Compared with usual care, brief psychoeducational videos played at the patient’s bedside appear to have a profound impact on subsequent pain and medical utilization in patients with acute whiplash [51][48][52].

Education and information given to patients must include the following information:

• To ensure a good prognosis after whiplash injury.
• Encourage return to normal activities as soon as possible and promote recovery through exercise
• Ensure that pain after whiplash is normal and the patient should continue to use analgesics to manage pain
• Recommendations against the use of soft collars [49] for exercise and/or for staying active have been shown to have more favorable outcomes for pain and disability [53]

More research is needed on type duration formats and education effects in different types of whiplash patients [48] [52].

WAD can consider different types of motion

• ROM exercises,
• McKenzie exercises
• Postural exercises
• Strengthening
• Motor control exercises.

Active treatment which consists:

• Active mobilization was applied gently on a small ROM and repeated 10 times in each direction also as homework [54]
• A home exercise program for acute WAD consisting of neck and shoulder ROM relaxation exercises and general recommendations, when used daily, is sufficient to treat patients with acute WAD [55].
• There is strong evidence that exercise programs and active mobilization can significantly reduce pain in the short term, and there is evidence that mobilization can also improve ROM [56][57][58][59][54][52].
• Spinal manipulation is commonly used in the clinical treatment of neck pain. A systematic review of the few trials evaluating manual therapy techniques alone concluded that manual therapy (eg, passive mobility applied to the cervical spine) may provide some benefit in reducing pain [47].
• Patients with WAD grades 1 and 2 show good results in a multimodal treatment program that includes exercise and group therapy manual therapy education and exercise. At their 6-month follow-up, 65% of subjects reported complete return to work 92% reported partial or complete return to work, 81% Reports no medical or paramedical treatment within 6 months[60]
• Collar use is in contrast to what is indicated in most studies; activates mobilization and exercise. Early exercise therapy has been shown to be superior to collar therapy in reducing pain intensity and disability in whiplash injuries. Other studies have also shown that exercise Therapy provides greater pain relief than soft collars [54][61][52].

Chronic Whiplash

• Chronic WAD is the result of a combination of injury and psychological factors [50][62]
• Patients with chronic WAD report poorer health than those with nonspecific chronic neck pain [63]
• A multidisciplinary approach of cognitive behavioral therapy and physical therapy including neck exercises is applied in the management of patients with chronic WAD. [64][50][65][66] It also gave positive results in terms of reductions in neck pain and sick days. [50].
• Behavioral therapy is used in treatment because it can reduce the intensity of a patient’s pain during problematic daily activities. That is, adjust the plan and treatment [67].
• An exercise program has a positive effect on pain reduction in the short term. An exercise program is the most effective non-invasive treatment for patients with chronic WAD and should be integrated with coordination exercises to reduce neck pain.
• Negative thoughts are a very important factor in patients with chronic WAD. [68]. Specialists and physical therapists can influence negative thoughts and pain behaviors by educating patients with chronic WAD about the neurophysiology of pain [69].
• Simple recommendations are as effective as more intense, comprehensive physical therapy exercise programs [70].
• Mirrored cervical alignment exercises and traction were used to reduce head protrusion and cervical kyphosis in a postural rehabilitation clinical biomechanical study. After 5 months, the patient’s chronic WAD symptoms improved [71].

Clinical Bottom Line

• For the management of chronic whiplash injuries, there is strong evidence that multidisciplinary treatment is effective. The therapy includes an exercise program. Early mobilization is most effective when other, more serious clinical pathology found on examination and diagnostic imaging has been ruled out go out.
• Prognosis varied by comorbidity before WAD age and severity of injury by socioeconomic environment. Full recovery has been shown to occur within days to weeks. However, disabilities can be permanent and range from chronic pain to impaired physical function.
• While cervical pain is the most common symptom, dizziness and/or headaches may be chronic and persistent. Chronic pain that in turn interferes with work and physical function can lead to loss of income and lifestyle.
• Diagnosis and treatment of WAD are complex and involve many complex issues. The legal environment, pre-injury comorbid age, and defensive medicine all play a role in management and outcome. Diagnosis varies widely, and persistence of symptoms largely depends on the law culture or the ability to seek compensation for WAD. [8]

Resources

In 2017, Walton and Elliot proposed a new comprehensive model of chronic WAD. This journal article explains more about the model

Walton DM Elliott JM. A comprehensive model of chronic whiplash-related disorders. Journal of Orthopedics and Sports Physical Therapy. 2017 Jul;47(7):462-71.

Practical assessment and treatment of cervicogenic headaches