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Whiplash: Diagnosis & Treatment

Return to Work and Prognosis
Most people can return to work in 1-2 weeks after whiplash injury, especially if they are involved in manual labour. Light duties can be imposed as a transition and are important in providing motivation to the patient.

The unclear prognosis of WAD is a major problem for clinicians and therapists, not only because it generates uncertainty in patient care but also because of the medico-legal requirements regarding insurance reports. Imaging studies of Grade 0-3 WAD have shown no convincing evidence of tissue injury. In a study of medico-legal cases it was shown that 79% of cases returned to work within one month, 86% returned within three months and 91% had returned within six months.

It seems that patients who are symptomatic after three months will remain so after two years or more, although their symptoms will fluctuate in this period. One further study suggested that most patients who still have symptoms two years after the accident will still have those symptoms at ten years, although their severity may change somewhat in the meantime.

Poor prognostic factors

  • Multiple symptoms early after injury
  • Increase in age
  • Young females have slower early progress
  • Neurological deficit in the first three days
  • Head position looking to one side at the time of impact
  • Pre-accident headache or neck pain

Cultural differences may influence recovery. Several studies have shown that cultures where compensation and expectation of social support do not exist seem to avoid chronic pain after WAD.

Medico-Legal Issues
The fact that the vehicle behind is nearly always at fault has important implications in litigation and disability payment. The fact that the accident is often low impact and symptoms are delayed has often been described as medically unexplainable and related to the litigation process. WAD sufferers have been perceived as neurotic or malingering. Although this was a common perception in the past, it has been repeatedly shown that litigation and compensation issues do not materially affect the medical course of WAD.

In a study comparing litigents with chronic pain and non-litigents, among those with chronic pain there were no significant differences in the amount of medication used and in the number of hours spent resting per day or actually in the length of time before return to work. Litigation did, however, predict the occurrence of depression.

Patients involved in litigation should be aggressively managed and have the same opportunities for rehabilitation as those not engaged in litigation. The evidence suggests that the development of chronic symptoms is influenced more by psychological, social or cultural factors.

Whiplash Associated Disorders and Review of the Literature to Guide Patient Information and Advice, T McClune, A K Burton, G Waddell Emerg Med J 2002; 19:499-506.
Persistent symptoms after whiplash injuries, implications for prognosis and management P Curtis, A Spanos, A Reid, Journal of Clinical Rheumatology Volume 1 No. 3 June 1995.
Hirsch SA, Hirschsa PJ, Hiramoto H, Weiss A. Whiplash Syndrome, Fact or Fiction. Orthop Clin North Am 1988; 19:791-795.
Mendelson G. Compensation and Chronic Pain, Pain 1992; 48:121-123.
Solomon P, Tunkse. The Role of Litigation in Predicting Disability Outcomes in Chronic Pain Patients.  Clin J Pain 1991; 7:300-304.
QTF – Quebec Task Force on Whiplash 1995.
BCWI – British Columbia Whiplash Initiative.
The Whiplash Book published by The Stationery Office – www.tso.co.uk/bookshop.