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Whiplash: Diagnosis & Treatment

Mechanisms Involved in Whiplash

Different mechanisms have been suggested as a cause of prolonged symptoms after whiplash type injury.  

Apophyseal Joint Instability
Facet joints may be separated excessively during a rear end collision and may never recover their stable apposition. Chiropractors, osteopaths and many physiotherapists do have training in detection of minor instability in spinal joints and there is some evidence that they can make accurate mobility assessments.

Trigger Points
Sudden stretch of muscular nociceptors can create trigger points such that muscle around the cervical spine becomes hypersensitive and tender to palpation. This can lead to weakness of cervical stabilising muscles along with stiffness of movement. Myofascial trigger points can be demonstrated through examination and there is evidence that fibromyalgia can develop as a result.  

Nerve Injury
After this type of injury, many nerves can become hypersensitive to stimuli causing spontaneous neuropathic type pain and abnormal sensations. Nerve roots may be compressed as a result of oedema, scarring or osteophyte formation although routine radiological studies may be negative.

Postural Dysfunction
Changes in posture due to any of these mechanisms may alter the loading on spinal joints and muscles. Most commonly, the head can be drawn down and forwards by tight muscles and a flexion contracture.  

Brain Injury
Experimentally, a whiplash injury can cause haemorrhages or contusions of the brain even though there is no direct injury. This may account for the cognitive and behavioural symptoms occurring after some road traffic accidents. Although unproven, injury to the sympathetic trunk, particularly at the C3/4 level, could cause deafness, visual blurring, vertigo and tinnitus through the ciliospinal reflex and accommodative dysfunction.  

Most of the proprioceptive receptors of the vestibulospinal tracts are found in the deep muscles of the neck and joint capsules of the first through to the third cervical vertebrae. These are major regulators of equilibrium. There may also be damage to the inner ear function leading to poor balance and postural control.  

Degenerative Arthritis
Some studies have shown that spondylosis occurs more often after whiplash injury but some of the evidence is conflicting and some of the studies are inadequate. Although based on the experience with knees and hips, one would expect degenerative change to be a likely consequence of injury.

Other studies have shown no link between WAD or the development of degeneration in the cervical spine. Much is to be gained from information and hypotheses put forward by osteopaths, chiropractors and physiotherapists regarding the aetiology and treatment of whiplash injury.

Diagnosis
A full examination of the neck, shoulder and thoracic spine should be carried out using active and passive movements along with a neurological examination of the upper and lower extremities and cranial nerves. Upper limb tension testing (ULTT) is also an invaluable aid to diagnosis.

The Quebec Taskforce Classification of Whiplash Association Disorders

  • Grade 0: No complaint of neck pain and no physical signs.  
  • Grade 1: Neck pain, stiffness or tenderness only - no
  • physical signs
  • Grade 2: Neck complaints AND musculoskeletal signs - decreased range of movement and point tenderness 
  • Grade 3: Neck complaint AND neurological signs - decreased or absent tendon reflexes, weakness and deficits
  • Grade 4: Neck complaints AND fracture or dislocation.

Imaging is usually unhelpful in WAD as the problem is normally due to dysfunction and not a structural injury.  Flexion-extension views of the cervical spine could be considered for any patient in whom neck motion causes an unexpected amount of pain two months after the initial injury. These X-ray views can detect intervertebral instability. Positive findings are rare but important when found, as surgical fusion may be curative.