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Whiplash: Diagnosis & Treatment

Management
A wide range of treatments has been proposed for WAD, ranging from spinal manual therapy, manipulation and traction to facet joint injections, acupuncture, massage etc.

Common recommendations for an acute injury include rest, intially using a soft or hard collar with ice compresses, gentle massage and a gentle range-of-motion exercise for the first few days. The length of time a collar should be worn is still in question but many authorities advise against this use for more than a few days.  Postural guidance on sitting and sleeping using an orthopaedic pillow is helpful in maintaining the alignment of the cervical spine. Analgesics, including low dose tricyclics, may be useful for pain relief but there is no good evidence to support the use of any particular analgesic.

Other Empirical Therapies include:

  • Muscle stretching
  • Trigger point therapy
  • Myofascial techniques
  • High velocity low amplitude manipulation
  • Transcutaneous electrical nerve stimulation (TENS)
  • Mobilisation
  • Postural training
  • Traction

There is increasing evidence that some of these treatments can be helpful in whiplash, but one must remember that for the therapies with no proof of efficacy, "absence of evidence" is not "evidence of absence".

Manipulation is wildly used by osteopathic and chiropractic therapists and increasingly so by physiotherapists. This technique treats the hypomobile segments and frees up apophyseal joint dysfunction. Manipulation is helpful in the acute and chronic phases of WAD, preferably a short course lasting no more than eight weeks.

Manual Therapy
Many different approaches are used within the professions of physiotherapy, osteopathy and chiropractic. The type of treatment depends upon the nature and severity of the injury, as well as the stage of presentation. As a rule, but by no means exclusively, osteopaths and chiropractors address the issues of mobilisation of hypo-mobile segments within the cervical and thoracic spine, whilst physiotherapists have become increasingly aware of the benefits of teaching exercises to enable the patient to "recruit" the deep stabilising muscles of the cervical spine. Many practitioners now use dry needling, which addresses trigger points and areas of hypersensitive musculature.

It is obvious nowadays that these professions are gaining a wealth of experience from each other and there is a significant crossover of technique usage, providing each practitioner with a coherent armamentarium of patient specific approaches. The musculoskeletal physician can provide the first point of contact and guidance to enable full benefit from the integrated approach. He or she can add in adjunctive treatments such as facet joint injections, nerve root injections, prolotherapy, drug therapy, cervical epidural injections etc.

The musculoskeletal physician can also decide to recruit a clinical psychologist if it would appear that cognitive behavioural or therapy should be added in to the treatment regime. It has been shown consistently in randomised controlled trials that an early active management strategy is most effective for whiplash associated disorders, including return to pre-accident activity as soon as possible. Psycho-social interventions, including cognitive behavioural therapy, can also help in achieving early activation. Chronic symptoms can sometimes be treated with radio frequency de-nervation or prolotherapy injections but the relation between the symptoms and the injury may be uncertain.

It is also appropriate that educative advice is given to the patient and there is evidence that this is helpful in other musculoskeletal conditions. Evidence based patient education has been shown to be effective in shifting attitudes and proving clinical outcomes as well as reducing time lost from work.

The Quebec Taskforce (QTF) on whiplash associated disorders (WAD) suggested that information is an essential part of an active management approach and along with the British Columbia Whiplash Initiative (BCWI) this lead to the production of the "Whiplash Book".

The Whiplash Book has been produced within the last two years, based on the latest medical research. Its effectiveness has been assessed in a study by T McClune, A K Burton and G Waddell, that concluded the book was found acceptable to patients and capable of improving beliefs about whiplash and its management. It seems suitable for use in the A&E environment and for wider distribution at population level. Only an RCT would determine whether it has an effect on behaviour and clinical outcomes.

Encouragement of a favourable prognosis along with an early return to normal activity and work should be a major part of an active management programme.

The ideal system is a physician co-ordinated, patient centred, multi-modal approach tailored to the patient, depending on the history, symptoms and signs of the presenting case. We use this system at The Blackberry Clinic in Milton Keynes.