Whiplash Treatment

The spectrum of whiplash treatment is a reflection of the diversity of pathology which is encountered and may in turn lead to a variety of clinical manifestations now referred to as whiplash associated disorders (WAD).

The initial guidelines on WAD were formulated in 1996 by the Quebec task force.

This patient group includes:

27% of subjects who still have pain 6 months post injury

15 – 20% of subjects develop persistent pain & disability

$29 Billion – The U.S. annual costs associated with WAD

Treatment

In general terms treatments involve a combination of:

● Manual Physical Therapy & Graded Exercise

● Deep Neck Flexor Endurance Exercise

● Patient Education on Staying Active

Evidence

Early referral to Physiotherapy results in superior short and long-term outcomes when compared to immobilization with a soft collar and advice to rest, even in patients with identified elevated psychological distress levels.

Associated mechanical thoracic spine impairments may be more prevalent in patients with WAD (69%) than in those with mechanical neck disorders (13%) and when treated with thoracic manipulation, patients with WAD demonstrate greater reductions in pain than patients with mechanical neck pain.

Retraining the deep cervical flexors in conjunction with manual therapy to the cervicothoracic spine can effectively decrease neck pain and headache with results being maintained at one-year follow-up.

Reassurance that there is no serious tissue damage, encouraging patients to stay active and maintain normal activities of daily living is effective in reducing delayed recovery.

Elevated psychological distress is a nearly uniform finding in patients suffering from acute WAD and is associated with several predictive factors

Prognostic Factors

≥26 pts on the Impact of Events Scale (IES) is indicative of patients with higher levels of post-traumatic stress reaction, adversely affected recovery, and more likely to benefit from specific treatment. In fact, an Neck Disability Index (NDI) score ≥30 combined with cold hyperalgesia results in a 10-fold increase in the odds of experiencing moderate to severe levels of posttraumatic stress.

Higher initial scores on the Neck Disability Index (NDI), older age, cold hyperalgesia and higher acute post-traumatic stress levels accurately are predictive of those who will experience moderate to severe symptoms at 6 months.

Management

Patients with Quebec Task Force WAD Grade I-III as early in the course of care as possible. This would include patients with headaches and non-progressive neurological symptoms

In particular, patients with the following factors should be referred in order to decrease the probability of developing chronic symptoms:

● IES score ≥26 pts

● NDI score ≥30 pts

● Older patients

● Cold Hyperalgesia

The key clinical issues are to determine if a patient has factors predictive of chronicity and the likelihood they would benefit from physiotherapy intervention.

Sterling’s Modified classification (2004)

WAD 0	No signs
WAD 1	Complains of stiffness & tenderness No physical signs
WAD 1A	Neck pain, Motor impairments, Reduced ROM, Local Hyperalgesia
WAD 1B	As 1A + Psychological distress
WAD 1C	As 1B + proprioceptive impairments, diffuse pain pattern, Post – traumatic stress
WAD 2	As Quebec
WAD 3	As Quebec
WAD 3	As Quebec

The suggested modifications are aimed at selecting sub-groups of patients where more specific whiplash treatment can be devised based on the spectrum of clinical signs and incorporating psychosocial factors and pain mechanisms.

Enjoy the clinical challenge.
David