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Whiplash: Diagnosis & Treatment

by Dr Simon Petrides MB BS DO DM-SMed Dip Sports Med FFSEM (UK&I)
Musculoskeletal & Sports Physician | The Blackberry Clinic, Milton Keynes

Prevalence
Most cases of Whiplash Associated Disorder (WAD) result from car accidents. About 20% of car accidents are rear end collisions and these are the ones that typically cause whiplash type injury. About one person in fifty is hurt every year in a car accident and the resultant medical and insurance implications run into many millions of pounds annually. This is not helped by the increasingly litigious culture in which we live.

When struck from behind, a car will accelerate forwards followed about 100 milliseconds later by the torso and shoulders. The head, because of its weight, lags behind and is then catapulted forward. This applies force of up to 100lbs to the head, producing maximal hyperextension well beyond the physiological limit.

The direction of impact has an influence since a higher velocity change is required for tissue damage in a front or side impact, compared with a rear impact, collision. Poorer prognosis is likely if the neck is rotated at the time of impact.  

Well positioned head restraints do not prevent WAD type injury, although they have been shown in some studies to reduce the incidence and severity if positioned close to and level with the head. Seatbelts, although they reduce the risk of fatal injuries, may actually increase the severity of WAD. This may be due to an increase in force between the torso and the head when the vehicle is jolted.

Symptoms of WAD

  • Headache
  • Tiredness
  • Neck pain and stiffness
  • Paraesthesia
  • Low back pain
  • Dizziness
  • Poor concentration
  • Blurred vision
  • Visual disturbance
  • Irritability
  • Sleep disturbance
  • Noise sensitivity
  • Forgetfulness
  • Anxiety

A number of these symptoms have been collectively called the Barré-Lieou Syndrome. In 1925, Jean Alexandre Barré, MD, a French Neurologist, and in 1928 Yong-Choen Lieou, a Chinese physician, each independently described a syndrome with a variety of symptoms thought to be due to a dysfunction in the posterior cervical sympathetic nervous system. The posterior cervical sympathetic syndrome became known as Barré-Lieou Syndrome.

Symptoms that characterise the syndrome include headache, neck, facial, ear and dental pain, tinnitus, vertigo (dizziness), nausea, vomiting, blurred vision, watering of the eyes and sinus congestion. Other symptoms may include swelling on one side of the face, localised cyanosis of the face, facial numbness, hoarseness, shoulder pain, dysaesthesia of the hands and forearms, muscle weakness and fatigue. These symptoms correlate very closely with those experienced after some whiplash type injuries and may indeed be part of the spectrum of WAD.


Whiplash injury can certainly trigger emotional and cognitive changes, including:

  • Travel anxiety
  • Post traumatic stress disorder
  • Depression
  • Fear of movement
  • Sleep disturbance
  • Lower levels of concentration

The evidence suggests that the development of chronic symptoms is influenced more by psychological, social or cultural factors.

Pathophysiology
Autopsy studies have shown that in severe whiplash, damage is caused by the sheer force to bone, joints, ligaments, muscles and nerves. Haemorrhages and haematomas occur in the neck muscles along with tears in the inter-spinous and supra-spinous ligaments. The main clinically important structures involved are the  apophyseal joints, the intervertebral discs and the intervertebral ligaments. Often there is immediate pain or the onset may be delayed up to 48 hours. This implies a more neuro-muscular origin to the pain. The delayed onset improves the prognosis.

The nerves that may be involved include the accessory nerve, the cervical sympathetic chain and the vertebral nerves. There may be a resultant vertebral artery spasm and ischaemic effects on the brain stem. Temporo- mandibular joint function may also be disturbed due to the mechanical forces during the injury.

Very often MRI and CT scans, along with radiographs, are mostly normal as are electromyograms.

Progress of Symptoms
Most patients recover within about two months but in a significant minority the symptoms may continue for years or indefinitely.

Headache
Headache is a common pain experienced after whiplash injury. This may be caused by muscle contraction or tension but it may be secondary to other tissue injury in the cervical spine. The headache may be unilateral and throbbing in nature which suggests a vascular cause. The headaches can resemble migraines or they may be focal and stabbing in nature. Some patients also complain of pain, numbness, tingling, coldness or weakness in one or both arms. Other symptoms include dysphagia, blurred vision, Horner's Syndrome, tinnitus, hearing loss, dizziness, fatigue and cognitive deficiencies. These symptoms may be related to damage of the cervical sympathetic chain.

Low back pain can occur in 42% of accidents and this type of low back pain will often come on several days or weeks after the accident. Data from retrospective studies suggests that persistent symptoms are more likely to develop if the patient has pain or parasthaesia in the arms or if there is evidence of pre-existing degenerative change on X-ray. If there is a reversal of lordosis or if abnormal neurological signs are present, these may also be indicators of a poor prognosis.  

There is increasing evidence that a proportion of victims develop behavioural or psychiatric problems. For example, in a study of 63 whiplash victims with no other injury, 18% had a phobic anxiety at three months and 12% at one year after the accident. 5% had post traumatic stress disorder at one year and 18% suffered from travel anxiety. Compensation did not predict these outcomes.


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.


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.


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.

Source
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.