Whiplash Associated Disorders

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Clinically Relevant Anatomy

Whiplash and whiplash associated disorders (WAD) affects variable areas of the cervical spine, depending on the force and direction of impact as well as many other factors. In a whiplash injury, bony structures, ligamentous structures, muscles, neurological structures, and other connective tissue may be affected. Anatomic causes of pain can be any of these structures, with the strain injury resulting in secondary edema, hemorrhage, and inflammation.

Mechanism of Injury / Pathological Process

The mechanism of injury is variable, usually involving a motor vehicle accident but also including causes such as sports injury, child abuse, blows to the head from a falling object, or similar accelleration-decceleration event.

Clinical Presentation

The most common presentation will be sub-occipital headaches and/or neck pain that is constant or motion-induced. There may be up to 48 hrs delay of symptom onset from the initial injury. Other signs include neurologic signs, dizziness, tinnitus, visual disturbances, UE radicular pain, difficulty sleeping due to pain, and difficulty concentrating/poor memory. (eMedicine) It is important to provide a thorough spinal exam and neurologic exam in patient with WAD to screen for delayed-onset of cervical spine instability or myelopathy.

QTFC (Quebec Task Force Classification)

The Quebec Task Force was a task force sponsored by a public insurer in Canada.  They submitted recommendations regarding classification and treatment of WAD, which was used to develop a guide for managing whiplash in 1995.  An updated report was published in 2001.  Each of the grades corresponds to a specific treatment recommendation.

QTFC Grade	Clinical presentation
0	No complaint about neck pain No physical signs
I	Nec complaints of pain, stiffness or tenderness only No physical signs
II	Neck complaint Musculoskeletal signs including decreased ROM point tenderness
III	Neck complaint Musculosceletal signs Neurological signs including: decreased or absent deep tendon reflexes muscle weakness sensory deficits
IV	Neck complaint and fracture or dislocation

MQTFC (Modified Quebec Task Force Classification)

Proposed classification grade	Physical and psychological impairments present
WAD 0	No complaints about neck pain No physical signs
WAD I	No complaints of pain, stiffness or tenderness only No physical signs
WAD IIA	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) Sensory Impairment local cervical mechanical hyperalgesia
WAD IIB	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) Sensory Impairment local cervical mechanical hyperalgesia Psychological impairment elevated psychological distress (GHQ, TAMPA)
WAD IIC	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) increased JPE Sensory Impairment local cervical mechanical hyperalgesia generalized sensory hypersensitivity (mechanical, thermal, ULNT) Some may show SNS disturbances Psychological impairment elevated psychological distress (GHQ, TAMPA) elevated levels of acute posttraumatic stress (IES)
WAD III	Neck complaint Motor impairment decreased ROM altered muscle recruitment patterns (CCFT) increased JPE Sensory Impairment local cervical mechanical hyperalgesia generalized sensory hypersensitivity (mechanical, thermal, ULNT) Some may show SNS disturbances Neurological signs of conduction loss including: decrease or absent deep tendon reflexes muscle weakness sensory deficits Psychological impairment elevated psychological distress (GHQ, TAMPA) elevated levels of acute posttraumatic stress (IES)
WAD IV	Fracture or dislocation

Diagnostic Procedures

Canadian C-Spine Rule (CCR): algorithm to determine the necessity for cervical spine radiography in alert and stable patients presenting with trauma and cervical spine injury.

Canadian C-Spine Rule

Management / Interventions

Management approaches for patients with WAD are poorly researched. These patients often do not fit into treatment categories as defined for other cervical pain problems due to multiple factors, and even within the WAD group there are multiple variances which warrant individualized treatment approaches. The most recent evidence supports the use of Sterling's classification system for WAD.  

Differential Diagnosis

Cervical radiculopathy
Facticious disorder
Polymyalgia Rheumatica
Traumatic Brain Injury
Cervical herniated disk
Cervical myelopathy
Cervical osteoarthritis
Infection or osteomyelitis
Inflammatory rheumatologic disease
Malingering
Psychogenic pain disorder
Referred pain from cardiothoracic structures
Tumor or malignancy of cervical spine

Vascular abnormality of cervical structures

Key Evidence

"Whiplash associated disorders- redefining whiplash and its management" by the Quebec Task Force: a critical evaluation.

Resources

www.som.uq.edu.au/whiplash

Evidence-based summary

Case Studies

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References

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