Whiplash associated disorder

I work in private practice and as you may imagine I see my fair share of whiplash injuries. So I thought that I would write a blog article on the subject:

 

Definition:

"Acceleration - deceleration mechanisms of energy transfer to the neck"
"From motor vehicle collisions, but can also occur during other mishaps"
"Result in bony or soft tissue injuries, which may in turn lead to a variety of clinical manifestations called whiplash associated disorders (WAD).

Grading:

nGrade 0: no neck complaints or signs

n

I: pain, stiffness or tenderness, no physical signs

n

II: as I + musculoskeletal signs (MSK)

n

III: as I + neurological signs +/- MSK

n

IV: fracture or dislocation

n

Late whiplash: symptoms 6 months+

Mechanism of injury:

nBannister et al (2009)

–rear-end collisions account for half of cases, associated with more severe symptoms

nElliott et al (2009)

–0-50 milliseconds: cervical and thoracic spine straighten as car seat pushes torso forward

–50-75ms: abnormal “S-shaped” cervical curve of lower segmental extension and upper flexion

–

>100ms: maximal head and neck displacement: all cervical levels extended

 

Pathology:

 

nFacet joints

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haemarthroses (bleeding in the joint), capsular tears/rupture, articular cartilage damage, joint fractures. Involved in persistent pain: C2-3 (60%) then C5-6

n

Doral Root Ganglion and nerve roots

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vulnerable to stretching and injury due to location

n

Ligaments

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contribute to persistent symptoms

n

Disc

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C5-6 most common

n

Muscle injury

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sternocleidomastoid, superficial posterior

Symptoms:

nBannister et al (2009): most common neck pain and stiffness, occipital headache and upper limb paraesthesia (abnormal sensation) 

n

Elliott et al (2009)

–

psychological distress

n

CSP clinical guidelines (2005)

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shoulder and arm pain, generalised hypersensitivity, muscle weakness, TMJ pain (Jaw), visual disturbance, impaired proprioceptive control.

Assessment:

nSterling (2009)

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identify presence of adverse prognostic indicators as these will affect recovery. They can be physical and psychological:

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Physical

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high initial pain and disability levels

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early cervical movement loss (Elliott et al 2009)

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history of neck pain prior to accident

female (Walton et al 2009)

n

Psychological

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posttraumatic stress symptoms (Elliot et al 2009)

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catastrophizing (Walton et al 2009)

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passive coping, fear of movement (Carroll et al 2009)

What does the assessment consist of?

nScholten-Peeters et al (2009)

–

There are no validated diagnostic tests so general observation and cervical movement is looked at. 

–

neurological examination

muscular stability and proprioception (strength and control)

n

CSP (2005)

–Questioning about potential "red and yellow flags" (indicators to serious pathology and psychological issues)

nElliott et al (2009)

–Decrease movement is the most common characteristic

–The Impact of Event Scale (IES) for posttraumatic stress

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Neck Disability Index (NDI) to analyse progression

 

Treatment: 

CSP guidelines:

nAcute: (0-2 weeks post-injury)

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active exercise within 4 days to reduce pain

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self-management education to reduce symptoms

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encourage return to normal activities ASAP

n

Sub acute (2-12 weeks)

–multimodal program (postural training, manual techniques, psychological support) to reduce pain and aid return to work

n

 

Chronic (12 weeks plus)

 

Less complicated patients:

 

n

Symptoms

–Milder pain and disability (NDI <28/100)

–Movement loss, motor deficits and local hyperalgesia (high pain) 

–Lower levels of psychological distress

nMultimodal treatment approach

–Cognitive

nReassurance about prognosis and explain management plan

nProvide awareness of mechanisms underlying condition

–Physical

nincrease ROM, retraining of motor control

n

gentle manual therapy to C2/3 for hypoalgesic effect (to lower pain)

 

More complicated patients:

 

nSymptoms

–Mod/severe pain and disability (NDI >30/100)

–Movement loss and motor deficits

–Central hyperexcitability (nervous system is overactive)

–Posttraumatic stress symptoms (IES >26)

–Higher levels of psychological distress

nInterdisciplinary approach

–Emphasis on psychological and pain processing aspects

npsychological referral

npain relief

–Improve movement and function

nEncourage active exercises (no symptom provocation), gentle manual therapy and modalities (TENS)

Prognosis:

nCarroll et al (2009)

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50% report neck pain symptoms 1 year post injury

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recovery seems to depend on lots of factors

n

Kamper et al (2008)

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in the initial 3 months recovery occurs for many but after this recovery rates level off

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initially pain and disability reduce rapidly but show little improvement after 3 months

n

Sterling (2009)

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effective assessment and management in the acute stage to prevent chronicity

So this is why it is so important to seek Physiotherapy ASAP after the incident