Predicting Outcomes in Whiplash
Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur during sport (diving, snowboarding) and other types of falls. The impact may result in bony or soft-tissue injuries affecting the ligaments, muscles, and nerves and may lead to other clinical manifestations call whiplash associated disorders (WAD).   WAD is a term used to describe a collection of symptoms following a whiplash injury.  WAD symptoms range from neck pain, stiffness and tenderness, to loss of motor function and mental as well as stress reactions.  Usually patients recovery within 3 months after a whiplash injury but ½ of the patients with acute WAD go on to develop chronic pain and or disability.  To learn more about WAD you can click on the following link: Whiplash Associated Disorders
Early identification of the individuals that might have long term pain and disability will help clinicians to spend the correct resources in prevention and treatment. This subject is continually being researched and therapists should stay up to date with the current research on predicting factors. 
Factors that predict poor outcomes
High levels of initial pain and a high score on the neck disability index are considered the strongest predictors of pain and disability after 6 months.  Other strong predictors include cold hyperalgesia, older age, and acute post-traumatic stress. 
1. High level of initial pain
It is an easy scale for therapists and doctors to use and can be used to measure initial pain and pain levels with activities of daily living or work activities. 
2. Characteristics of pain
Presence of Neuropathic pain - listen to descriptors used by the patient in history taking - burning, electrical, mind of its own, area extra tender to touch. Allodynia.
- 10-item questionnaire, filled out by the patient asking the patient to rate activities of daily living for e.g. personal care, reading, driving, concentration, pain intensity, lifting, sleeping, recreation, and headache on a 0-5 scale indicating disability in these activities. 
- Along with pain intensity it is considered a very strong predictor of poor outcome in terms of chronic pain and disability
- greater than 14.5/50 
3. Psychological factors
- “Catastrophizing refers to an exaggerated negative orientation toward noxious stimuli” 
- It is considered multidimensional and consists of the following: 
- Rumination - when a person can’t stop thinking about the pain, especially how much it hurts
- Magnification - fearful thoughts that something serious might happen
- Helplessness - a feeling that there is nothing that can be done to alleviate the pain
- In general, these patients have a negative mindset on pain. They have passive coping skills like lying down, drinking pain medication, and expecting the clinician to fix them. They sometimes even look ill.
- “Most robust and reliable psychological predictor of pain experience” 
- Pain Catastrophizing Scale is a 13-item questionnaire where patients can rate the frequency of certain thoughts and feelings when they experience pain. 
- Catastrophizing is considered a significant risk factor 
- When reducing catastrophization in a patient the patient (acute/chronic) will have a decrease in pain severity and in disability 
- TAMPTA scale of kinesiophobia (TSK) is a 17-item questionnaire. It measures fear (re)injury due to movement. The scores range from 17 to 68 and a score of 37 is considered high. 
- Ask the patient what are they concerned about, what fears do they have. For e.g. do they think that their spine is fragile and can easily be damaged? What movements or exercises are they avoiding?
Post traumatic stress reaction
A combination of high levels of pain plus post traumatic stress are considered a high predictor of poor outcome after whiplash.
- Occurs in about 25% of people who sustain a whiplash in a motor vehicle accident 
- Characterized by 3 major symptom groups (clusters): 
- Re-experiencing of symptoms - intrusive thoughts about the accident coming to mind during the day, nightmares
- Symptom avoidance - social withdrawal, avoiding any stimulus or thoughts that remind of the accident
- Hyper aroused state - hyper vigilant, jumpy, irritable, high respiration rate
- Ask the patient how often do they think about the accident. Do they keep telling you about the accident?
- Measured by the Impact of Events Scale (IES). It is a 15-item questionnaire and screens for post-traumatic stress as it measures the current subjective stress regarding the specific life event. 
- The EIS was revised include questions about hyper-arousal. It is called the Impact of Events Scale - Revised (IES)-R and is a 22-item questionnaire. Link to the revised scale: (IES)-R
- IES should only be done 6 weeks after the injury as it is normal to have these intrusive thoughts before that.
Perception of injustice has been shown as a predictor of long term disability and pain after a whiplash injury
4. Physical factors
Widespread tenderness in areas not affected by the injury
- front of the shins
- widespread hypersensitivity - tested with blunt pressure 
Cold pain threshold alteration (hyperalgesia) - is associated with higher pain and disability 6 months after the whiplash. 
- When touched by metal at 15-20 degrees C feels like burning
- If the cold pain threshold decreases with even 1 degree compared to normal then the person have a high chance of developing moderate/severe symptoms in the long term 
- Considered a strong sensory predictor along with impaired sympathetic vasoconstriction 
- Thermal hyperalgesia (heat/cold) is seen soon after the whiplash injury in those individuals who develop ongoing moderate to severe pain/disability 
- Could be indicative of peripheral nerve damage, “changes in the central mediation of pain”, or changes in the sympathetic nervous system .
Positive Upper limb tension test 1 (ULTT1) or brachial plexus provocation test 
- A positive or heightened reaction is seen soon after the whiplash injury in those individuals who develop ongoing moderate to severe pain/disability
- In patients with chronic WAD the presence of a decrease in bilateral elbow extension with this test is indicative of motor and sensory changes due to central sensitisation
- For more information on this test follow the link to Neurodynamic Assessment
Additional factors to consider
Weaker predictors of risk - can help with the prognosis and intervention decision making but cause and effect cannot be shown 
- Female gender -- robust risk predictor 
- Report of low back pain with evaluation after the incident 
- Range of motion of the cervical spine and changes in neck muscle activation after whiplash is not considered a significant predictor of long term pain and disability. 
- Accident parameters as recalled by the patient is not considered a predictor for recovery. This might change in the future with more data from vehicles as technology improves. 
- Past medical history 
Some research exists of the beneficial interventions for the different phases of whiplash but further study is definitely indicated. Acute (< 2 weeks), subacute (2-12 weeks), chronic (> 12 weeks). Exercise and therapy that includes mobilisation has been studied the most an appears to be superior treatment in terms of acute and chronic WAD.  Moderate to aggressive mobilisation and exercise should be avoided in the acute and subacute phases. Interdisciplinary treatments are also extensively studied and psychological counseling combined with physiotherapy has better results than physiotherapy alone. 
General treatment strategies will be discussed below.
Studies have shown that patients can have a rapid improvement in symptoms within the first 90 days following the injury but then the recovery plateaus. A great number of patients experience ongoing pain and disability. This means that the first 3 months after the injury is crucial in the management of these patients. 
An interdisciplinary team approach is advised for patients that fall within in the moderate to high risk for long term pain and disability following a whiplash injury.
- This will include physiotherapy to restore ROM, pain treatment and medication for adequate pain relief, and psychology to specifically target the patient’s post traumatic stress reaction. 
Manage initial pain
- Reduce pain experience
- Neuropathic pain - manual therapy, aerobic exercise, local exercise to reduce pain experience. Neuropathic medication
- The intervention will change according to the goal set for this patient 
- If the goal is to return to work then the focus should be on graded activity and exposure
- If reducing pain levels is the goal then monitoring thoughts and restructuring cognitive behavior will be the objective
- Should be combined with other management techniques
- cognitive restructuring - list/document/discuss pain related thoughts. Draw out negative thoughts to make them aware of them. Do you think this is helpful? What use is that? Replace with positive thoughts.
Fear of movement and re-injury - controlled/supported exposure to feared activities. Support and coach them.
Post traumatic stress
- Early specific treatments for post traumatic stress is more effective than general cognitive behavioural therapy. 
- PTS reaction - outside PT domain/expertise (clinical psychologist, CBT, EMDR - eye movement desensitization reprocessing)
- Gentle desensitization techniques to treat widespread tenderness, exposure to aerobic exercise, slow and graded.
- Mobilisation programs includes activities that are aimed at improving or maintaining mobility 
- Strong evidence exists that active mobilisation is linked to less pain and some evidence that it might improve range of motion in acute WAD. 
- Neck Specific Exercise - Physiotherapist guided neck specific exercises has been shown to decrease disability after 3 months when compared to physical activity prescription 
Electromagnetic field therapy - some limited research has shown this to be effective 
Treatments deemed not effective
- Soft collar immobilization - may impede recovery 
- Laser acupuncture
- Education alone
- Exercise programs purely focused on strength and endurance and not on mobility 
- Some evidence show that methylprednisolone infusion is effective in acute WAD 
- NSAIDs might be helpful in the acute phase to reduce inflammation and pain but due to it's side effects should not be used for the long term. 
- No studies exist to show the effect of muscle relaxants, antidrepessants, or anticonvulsants and according to general consensus opioids should be avoided. 
Limited studies focus on this phase.
Interdisciplinary treatment is most effective with manual joint manipulation showing some benefit.
Rehabilitation done by a physiotherapist can produce meaningful changes in the symptoms of a patient with chronic pain after a whiplash. Exercises seems to be the most effective non-invasive treatment in this phase.  When treating chronic whiplash patients the focus should be on the following: 
- improving the impaired physical movements and activities
- working on the patient’s psychosocial abilities and activities
Manual therapy - joint manipulation has shown to be helpful as well as myofeedback training.  A multi-model physiotherapy approach was compared to a patient self-management program. Both groups improved with their NDI scores but more so in the physiotherapy group. The physiotherapy group also had a greater improvement in NPI scores.  The following treatments were included in the physiotherapy group:
- specific low load exercises for the neck flexor and extensor muscles as well as the scapular and postural muscles.
- kinesthetic exercises
- low velocity manual therapy techniques
- education on ergonomics, ADL, and work settings
Physiotherapy can aggravate some patients with chronic WAD and therefore the authors of this study chose only low load interventions.  However, when a patient has widespread mechanical and thermal hypersensitivity then physiotherapy should not be the only treatment these patients receive. 
It has been shown that psychological factors in chronic WAD could be due to ongoing pain and disability. Patients with increased psychological problems one week following the accident is related to the decrease in neck movement. Thus the longer the symptoms are present the greater the psychological impact becomes, as the pain and disability improves the psychological factors also improve. 
- Whiplash Associated Disorders
- Pain Catastrophizing Scale - Physiopedia
- Myrtveit SM, Skogen JC, Petrie KJ, Wilhelmsen I, Wenzel HG, Sivertsen B. Factors related to non-recovery from whiplash. The Nord-Trøndelag Health Study (HUNT). International journal of behavioral medicine. 2014 Jun 1;21(3):430-8.
- Walton DM, Elliott JM. An integrated model of chronic whiplash-associated disorder. journal of orthopaedic & sports physical therapy. 2017 Jul;47(7):462-71.
- Pedler A. The Pain Catastrophising Scale. Journal of physiotherapy. 2010 Jan 1;56(2):137.
- Spitzer WO. et al. (1995). Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management. Spine (Phila Pa 1976)., 20(8 Suppl), pp. 1-73.
- Daenen L, Nijs J, Raadsen B, Roussel N, Cras P, Dankaerts W. Cervical motor dysfunction and its predictive value for long-term recovery in patients with acute whiplash-associated disorders: a systematic review. Journal of rehabilitation medicine. 2013 Feb 5;45(2):113-22. [Accessed 14 June 2018] Available from: http://www.ingentaconnect.com/contentone/mjl/sreh/2013/00000045/00000002/art00001?crawler=true&mimetype=application/pdf
- Golbakhsh MR, Mirbolook G, Mirbolook AR, Noughani F, Siavashi B, Gholizadeh A. Effect of Mental and Behavioral Factors on Severity of Disability following Whiplash Injury. Trauma Monthly. 2017;22(6). [Accessed 14 June 2018] Available from: http://traumamon.portal.tools/71693.pdf
- Walton DM, MacDermid JC, Giorgianni AA, Mascarenhas JC, West SC, Zammit CA. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):31-43. [Accessed 14 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://www.jospt.org/doi/pdfplus/10.2519/jospt.2013.4507&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=z48iW5iCN8OOygTTnLfgDA&scisig=AAGBfm2vfvPVzZoOSqUFSR19jsevoaEIkQ
- SpineLive. Whiplash Reasons. Published Aug 2015. Available from: https://www.youtube.com/watch?v=svR1pClh4DE[last accessed 18 June 2018]
- Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R. Physical and psychological factors predict outcome following whiplash injury. Pain. 2005 Mar 1;114(1-2):141-8. [Accessed 14 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://www.academia.edu/download/46453352/Sterling_M_Jull_G_Vicenzino_B_et_al._Phy20160613-23878-ftxn8w.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=FI0iW9mYJo_-yQTEtJ-gCQ&scisig=AAGBfm3nqbcO77XbvxRcJiBocwgLwu5aGg
- Hendriks EJ, Scholten-Peeters GG, van der Windt DA, Neeleman-van der Steen CW, Oostendorp RA, Verhagen AP. Prognostic factors for poor recovery in acute whiplash patients. Pain. 2005 Apr 1;114(3):408-16. [Accessed 14 June 2018] Available from: http://www.academia.edu/download/41859453/Prognostic_factors_for_poor_recovery_in_20160201-7069-15o997z.pdf
- Scott W, Wideman TH, Sullivan MJ. Clinically meaningful scores on pain catastrophizing before and after multidisciplinary rehabilitation: a prospective study of individuals with subacute pain after whiplash injury. The Clinical journal of pain. 2014 Mar 1;30(3):183-90. [Accessed 14 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://sullivan-painresearch.mcgill.ca/pdf/abstracts/2014/Scottetal2014.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=BZIiW6rcGpLWygT11bHQCQ&scisig=AAGBfm0IwFurhAKGQz_pvBETeDEzxtLb6A
- Sullivan MJ, Rodgers WM, Kirsch I. Catastrophizing, depression and expectancy for pain and emotional distress. Pain. 2001 Mar 1;91(1-2):147-54. [Accessed 15 June 2018] Available from: http://sullivan-painresearch.mcgill.ca/pdf/abstracts/sullivanmar2001.pdf
- Sullivan MJ, Thibault P, Simmonds MJ, Milioto M, Cantin AP, Velly AM. Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain. 2009 Oct 1;145(3):325-31. [Accessed 15 June 2018] Available from: http://www.academia.edu/download/43075568/Pain_perceived_injustice_and_the_persist20160225-28621-1vu0w2l.pdf
- Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?–A preliminary RCT. Pain. 2007 May 1;129(1-2):28-34. [Accessed 14 June 2018] Available from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.611.9615&rep=rep1&type=pdf
- Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain. 2003 Aug 1;104(3):509-17. [Accessed 15 June 2018] Available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=11&ved=0ahUKEwjmhuWX0dbbAhUCVK0KHVlgDRQQFghdMAo&url=https%3A%2F%2Fpdfs.semanticscholar.org%2F07ff%2F7e81af852a6dcba56b5dba0f3fc9dba724e5.pdf&usg=AOvVaw0fCGn5gYPGxrzb1aFIs9SX
- Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, Sequeira K, Death B. A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1–overview and summary. Pain Research and Management. 2010;15(5):287-94. [Accessed 19 June 2018] Available from: http://downloads.hindawi.com/journals/prm/2010/106593.pdf
- Kamper SJ, Rebbeck TJ, Maher CG, McAuley JH, Sterling M. Course and prognostic factors of whiplash: a systematic review and meta-analysis. Pain. 2008 Sep 15;138(3):617-29. [Accessed 14 June 2018] Available from: http://www.academia.edu/download/41675199/Course_and_prognostic_factors_of_whiplas20160128-23571-1o7c4mo.pdf
- Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, Sequeira K, Death B. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2–interventions for acute WAD. Pain Research and Management. 2010;15(5):295-304. [Accessed 19 June 2018] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2975532/pdf/prm15295.pdf
- Ludvigsson ML, Peterson G, O’Leary S, Dedering A, Peolsson A. The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders. Clin J Pain. 2015 Apr;31(4):294-303. [Accessed 14 June 2018] Available from: http://www.academia.edu/download/43630977/The_Effect_of_Neck-specific_Exercise_Wit20160311-20625-1cp7azf.pdf
- Curatolo M. Pharmacological and interventional management of pain after whiplash injury. journal of orthopaedic & sports physical therapy. 2016 Oct;46(10):845-50. [Accessed 19 June 2018] Available from: https://www.jospt.org/doi/pdf/10.2519/jospt.2016.6906
- Physiopedia. Dr James Elliott - advice for clinicians from the latest whiplash research. Available from: https://www.youtube.com/watch?v=0bwhMfnUg6U [last accessed 18 June 2018]