Whiplash Associated Disorders: Difference between revisions

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== Definition/Description ==
== Definition/Description ==
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 (whiplash injury), which in turn may lead to a variety of clinical manifestations called Whiplash Associated Disorders (WAD)<ref>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.</ref>. It is estimated that about 30% to 50% of patients who sustain a symptomatic whiplash injury are going to report chronic, and potentially more widespread symptoms, classified as WAD<ref name=":19">Stace R. and Gwilym S. « Whiplash associated disorder: a review of current pain concepts. » Bone &amp; Joint 360, vol. 4, nr. 1. 2015. </ref>. WAD is a good example of a medical condition where there is often an apparent disconnect between the magnitude of injury and the magnitude of disability<ref name=":19" />.   
Whiplash associated disorders (WAD) is the term used to described injuries sustained as a result of sudden acceleration-deceleration movements. It is considered the most common outcome after "noncatastrophic" motor vehicle accidents.<ref>Walton DM, Elliott JM. An Integrated Model of Chronic Whiplash-Associated Disorder. J Orthop Sports Phys Ther. 2017;47(7):462-71. </ref> The term WAD is often used synonymously with the term Whiplash however whiplash refers to the mechanism of injury rather than the presence of symptoms such as pain, stiffness, muscle spasm and headache, in the absence of a lesion or structural pathology.<ref>Spitzer WO. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining" whiplash" and its management. Spine. 1995;20:1S-73S.</ref><ref name=":19" /> The prognosis of WAD is unknown and unpredictable, some cases remain acute with a full recovery while some progress to chronic with long term pain and disability<ref name=":19" />  Early intervention recommendations are rest, pain relief and basic stretching and stretching exercises.<ref name=":19">Stace R. and Gwilym S. « Whiplash associated disorder: a review of current pain concepts. » Bone &amp; Joint 360, vol. 4, nr. 1. 2015. </ref>
 
The short video below sums up WAD nicely
 
{{#ev:youtube|https://www.youtube.com/watch?v=jgMdL7vEga8|width}}<ref>3D4Medical - Cervical Whiplash | Trauma.  Available from:https://youtu.be/jgMdL7vEga8 (last accessed 22 April 2020)</ref>


== Clinically Relevant Anatomy ==
== Clinically Relevant Anatomy ==
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*[[Intervertebral_disc|intervertebral discs]] and cartilaginous endplates
*[[Intervertebral_disc|intervertebral discs]] and cartilaginous endplates
*muscles
*muscles
*ligaments: [[Alar_ligaments|Alar ligament]], [[Anterior_atlanto-axial_ligament|Anterior atlanto-axial ligament]], [[Anterior_atlanto-occipital_ligament|Anterior atlanto-occipital ligament]], [[Apical_ligament|Apical ligament,]] [[Anterior_longitudinal_ligament|Anterior longitudinal ligament]], [[Transverse_ligament_of_the_atlas|Transverse ligament of the atlas]]
*ligaments: [[Alar_ligaments|Alar ligament]], [[Anterior_atlanto-axial_ligament|Anterior atlanto-axial ligament]], [[Anterior_atlanto-occipital_ligament|Anterior atlanto-occipital ligament]], [[Apical_ligament|Apical ligament,]] [[Anterior_longitudinal_ligament|Anterior longitudinal ligament]], [[Transverse Ligament of the Atlas|Transverse ligament of the atlas]]
*bones: [[Atlas|Atlas]], [[Axis|Axis]], vertebrae (C3-C7)
*bones: [[Atlas|Atlas]], [[Axis|Axis]], vertebrae (C3-C7)
*nervous systems structures: nerve roots, spinal cord, brain, sympathetic nervous system
*nervous systems structures: nerve roots, spinal cord, brain, sympathetic nervous system
*the vascular system structures: internal carotid and [[Vertebral Artery|vertebral artery]]
*the vascular system structures: internal carotid and [[Vertebral Artery|vertebral artery]]
*adjacent joints: [[Temporomandibular_joint|Temporomandibular joint]],  thoracic spine, ribs, shoulder complex
*adjacent joints: [[TMJ Anatomy|Temporomandibular joint]],  thoracic spine, ribs, shoulder complex
*the peripheral vestibular system
*the peripheral [[Vestibular System|vestibular]] system
 
[[Image:Whiplash Injuries.jpg|border|center]]
 
==Pathology==
Several lesions may occur, depending on the movement of the head during the accident. These lesions ranks from severe to moderate to slight. Hyperextension is the most common mechanism, followed by hyperflexion and lateral flexion.6
 
===Severe lesions===
Hyperextension and distraction of the neck may rupture the anterior longitudinal ligament and also some discs. A ruptured disc can lead to backward displacement of the vertebra lying above it – the upper facets then slide downwards on the lower – with damage to the spinal cord as a result.7 Spinal cord injuries after motor vehicle accidents occur most often in young car users in the 15–24 year age group.8,9
Pure hyperextension may also lead to compression of the spinal cord in those cases where retrolisthesis or spinal stenosis already existed. Compression fractures of the posterior elements may occur in other cases.
Hyperflexion injury may lead disruption of posterior ligaments and occasionally facet joint luxation and/or to fractures of the vertebral body (most fractures of the atlas10 and of the axis11 are the result of motor vehicle accidents).
Less likely, lesions of veins, arteries, neural structures, oesophagus and retropharyngeal tissues may occur.
 
===Other lesions===
 
Less severe lesions which may involves the intervertebral discs, the zygapophyseal joints, the cervical ligaments and muscles are much more frequent. These lesions may occur in isolation but are more often combined and therefore are sometimes difficult to recognize. The common complaint is neck pain.
 
====Discodural and discoradicular interactions ====
According to recent retrospective studies, the occurrence of disc lesions after whiplash injury is quite high12,13 and one prospective study indicates the value of clinical diagnosis.14 Most disc lesions are  ruptures of the anterior annulus fibrosus and endplate avulsions.
As the result of the hyperextension element during the trauma the disc may have fissured. The subsequent flexion or hyperflexion element causes displacement of disc material in a posterior direction. Davis et al describe a number of posterolateral disc lesions with radicular symptoms as the result of a hyperextension whiplash trauma.12 These herniations seemed to develop only after the acute phase and it took a few weeks for the radicular symptoms to manifest. In postmortem studies,  Taylor et al describe the intervertebral disc as the most frequently damaged structure.15–17 Jónsson et al18 also confirmed the large number of disc lesions after whiplash, and during surgery were able to confirm the findings from magnetic resonance imaging (MRI).
Posterocentral protrusions lead to central, bilateral or unilateral pain in a multisegmental distribution: pain in the neck, upper scapular area and trapezius. On examination, a symmetrical (mimicking a full articular pattern) or asymmetrical pattern of limitation is evident. In acute cases the picture may be torticollis-like.
 
====Facet joint problems====
Whiplash may also lead to problems at the level of the zygapophyseal joint capsules.19 Lord et al undertook a placebo-controlled prevalence study after whiplash and found that chronic cervical facet joint pain was common.20
Pain which is usually localized  is felt unilaterally. A convergent or divergent motion pattern may occur, although any asymmetrical pattern is compatible.


====Ligamentous lesions====
[[Image:Whiplash Injuries.jpg|border|center|frameless|400x400px]]
Minor lesions can occur when ligaments can become overstretched,12 or may become adherent as the result of post-traumatic immobilization. They manifest with vague stretching pain felt at the end of range of those movements that stretch the ligament.  


====Muscular lesions====  
==Pathology==
Muscular lesions which are mostly anterior  are described in clinical studies,21,22 on echography( the use of ultrasound as a diagnostic aid),23 in experiments in animals24,25 and in postmortem studies.26 Muscles, especially their occipital insertions, can be strained during injury. The subsequent pain will be quite localized and can be reproduced during either contraction or stretching.  
Most WADs are considered to be minor soft tissue-based injuries without evidence of fracture. 


The injury occurs in three stages:  
* Stage 1: the upper and lower spines experience flexion in stage one
* Stage 2: the spine assumes an S-shape while it begins to extend and eventually straighten to make the neck lordotic again.
* Stage 3: shows the entire spine in extension with an intense sheering force that causes compression of the facet joint capsules.
Studies with cadavers have shown the whiplash injury is the formation of the S-shaped curvature of the cervical spine which induced hyperextension on the lower end of the spine and flexion of the upper levels, which exceeds the physiologic limits of spinal mobility. 


== Epidemiology/Etiology ==
The Quebec Task Force classifies patients with WAD (whiplash), based on the severity of signs and symptoms, as follows: 
# Grade 1 the patient complains of neck pain, stiffness, or tenderness with no positive findings on physical exam. 
# Grade 2 the patient exhibits musculoskeletal signs including decreased range of motion and point tenderness.   
# Grade 3 the patient also shows neurologic signs that may include sensory deficits, decreased deep tendon reflexes, muscle weakness.
# Grade 4 the patient shows a fracture<ref name=":41">Bragg KJ, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK541016/ Cervical (Whiplash) Sprain.] InStatPearls [Internet] 2019 Apr 10. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK541016/ (last accessed 2.2.2020)</ref>.  
== Etiology ==
Whiplash-associated disorders describe a range of neck-related clinical symptoms following an MVA or acceleration-deceleration injury.  The pathophysiology underpinning this disorder is still not fully understood and many theories exist.  Some of the symptoms are thought to be caused by injury to the following structures: 
* Cervical Spine Facet Joint Capsule
* The facet joints
* Spinal ligaments
* Nerve roots
* Intervertebral discs
* Cartilage
* Paraspinal muscles causing spasms
* Intraarticular meniscus.<ref name=":41" />


WAD is considered to be "the most common nonhospitalised injury resulting from a road traffic crash".<ref name=":38">Ritchie C, Hendrikz J, Kenardy J, Sterling M. Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury. PAIN®. 2013 Oct 1;154(10):2198-206. Available from: http://www.udptclinic.com/journalclub/sojc/13-14/November/Ritchie%202013.pdf [Accessed 23 March 2018]</ref>   Based on several studies, we can conclude that the prevalence of WAD depends on the country or the part of the world. For example, the prevalence per 100,000 inhabitants is of 70 in Quebec, 106 in Australia and 188–325 in the Netherlands.<br>But according to the study of Versteegen, in which he studied patients with neck pain following a car accident in the last ten years, the prevalence per 100,000 inhabitants increased significantly from to 3.4 in 1974 to 40.2 in 1994. A study by Richter also shows an increase in prevalence of 20% between 1985 and 1997. The increase is due in part to a higher number of cars on the roads, which in turn can lead to more accidents. However, this increase in prevalence is also due to the fact that there is a greater public awareness of WAD and therefore those affected are more likely to consult their doctor and therefore the number of patients seeking healthcare for whiplash is on the rise<ref name=":7" /><ref name=":8" />.  
=== Epidemiology ===
The most common cause of WAD is MVAs, but it also occurs as a result of sporting injuries and falls. A study by Holm et al suggested that the numbers reporting symptoms has grown increasingly in recent years; in their paper published in 2008 they suggested that the incidence in North Ameria and Europe is approximately 300 per 100,000 inhabitants<ref>Holm LW, Carroll LJ, Cassidy JD, Hogg-Johnson S, Côté P, Guzman J, Peloso P, Nordin M, Hurwitz E, van der Velde G, Carragee E. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics. 2009 Feb 1;32(2):S61-9.</ref>.  In the UK the introduction of the compulsory wearing of seatbelts in 1983, an initiative to save deaths on the road, actually led to an increase in the number of reported WADs in the years<ref>Minton R, Murray P, Stephenson W, Galasko CS. Whiplash injury—are current head restraints doing their job?. Accident Analysis & Prevention. 2000 Mar 1;32(2):177-85.</ref>.   It is also more common in women than men with almost two-thirds of women experiencing symptoms and several studies found that women tended to a slower or incomplete recovery.compared to men<ref>Carroll LJ, Holm LW, Hogg-Johnson S, Côté P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, Van Der Velde G, Peloso PM. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics. 2009 Feb 1;32(2):S97-107.</ref>.  


The risk that patients develop WAD after an accident with acceleration-deceleration mechanism of energy transfer of the neck depends on a variety of factors:
The risk that patients develop WAD after an accident with acceleration-deceleration mechanism of energy transfer of the neck depends on a variety of factors:
* severity of the impact, however, it is difficult to obtain objective evidence to confirm this<ref name=":7">HOLM L.W. (2008). The Burden and Determinants of Neck Pain in Whiplash-Associated Disorders After Traffic Collisions: Results of the Bone and Joint Decade 2000 –2010 Task Force on Neck Pain and Its Associated Disorders. Eur Spine J., 17(Suppl 1), pp. 52–59.</ref>.
* Severity of the impact, however, it is difficult to obtain objective evidence to confirm this<ref name=":7">HOLM L.W. (2008). The Burden and Determinants of Neck Pain in Whiplash-Associated Disorders After Traffic Collisions: Results of the Bone and Joint Decade 2000 –2010 Task Force on Neck Pain and Its Associated Disorders. Eur Spine J., 17(Suppl 1), pp. 52–59.</ref>.
* neck pain present before the accident is a risk factor for acute neck pain after collision<ref name=":8">Loppolo F. et al. (2014). Epidemiology of Whiplash-Associated Disorders. Springer-Verlag Italia.</ref>.
* Neck pain present before the accident is a risk factor for acute neck pain after collision<ref name=":8">Loppolo F. et al. (2014). Epidemiology of Whiplash-Associated Disorders. Springer-Verlag Italia.</ref>.
* women seem to be slightly more at risk of developing WAD.  
* Women seem to be slightly more at risk of developing WAD.  
* Age is also important; younger people (18-23) are more likely to file insurance claims and/or are at greater risk of being treated for WAD<ref name=":1">Cassidy JD. et al. (2000). Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med., 342(16), pp. 1179-86</ref><ref name=":9">McClune T. et al. (2002). Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J,19, pp 499–506 </ref>.
* Age is also important; younger people (18-23) are more likely to file insurance claims and/or are at greater risk of being treated for WAD<ref name=":1">Cassidy JD. et al. (2000). Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med., 342(16), pp. 1179-86</ref><ref name=":9">McClune T. et al. (2002). Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J,19, pp 499–506 </ref>.
JD Cassidy and Scholton-Peeters demonstrated in their studies that 14 to 42 % of the whiplash patients are at risk of developing chronic complaints (longer than 6 months) and that 10 % of those have constant severe pain. The number of people worldwide who suffer from chronic pain is between 2 and 58 %, but lies mainly between 20 and 40%<ref name=":8" />.  If patient still have symptoms 3 months after the accident they are likely to remain symptomatic for at least two years, and possibly for much longer<ref name=":9" />.  50% of people with injury from whiplash will have a full recovery, 25% may have mild levels of disability and the rest moderate to severe pain and disability<ref name=":38" />
The number of people worldwide who suffer from chronic pain is between 2 and 58% but lies mainly between 20 and 40%<ref name=":8" />.   
 
* If a patient still has symptoms 3 months after the accident they are likely to remain symptomatic for at least two years, and possibly for much longer<ref name=":9" />.   
* 50% of people with injury from whiplash will have a full recovery,  
* 25% may have mild levels of disability and the rest moderate to severe pain and disability<ref name=":38">Ritchie C, Hendrikz J, Kenardy J, Sterling M. Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury. PAIN®. 2013 Oct 1;154(10):2198-206. Available from: http://www.udptclinic.com/journalclub/sojc/13-14/November/Ritchie%202013.pdf [Accessed 23 March 2018]</ref>
There are many prognostic factors that determine the evolution of WAD and the likelihood that it will evolve into chronic pain.  
There are many prognostic factors that determine the evolution of WAD and the likelihood that it will evolve into chronic pain.  


*It has been found that a poor expectation of recovery, passive coping strategies, and post-traumatic stress symptoms are associated with chronic neck pain and / or disability after whiplash<ref>Campbell L, Smith A, McGregor L, Sterling M. Psychological Factors and the Development of Chronic Whiplash-associated Disorder(s): A Systematic Review. Clin J Pain. 2018;34(8):755-68.</ref>
*Pre-collision self-reported unspecified pain, high psychological distress, female gender and low educational level predicted future self-reported neck pain<ref name=":2">Algers G. et al. Surgery for chronic symptoms after whiplash injury. Follow-up of 20 cases: Acta Orthop Scand. 1993 vol. 64, nr. 6 p. 654-6</ref>.  
*Pre-collision self-reported unspecified pain, high psychological distress, female gender and low educational level predicted future self-reported neck pain<ref name=":2">Algers G. et al. Surgery for chronic symptoms after whiplash injury. Follow-up of 20 cases: Acta Orthop Scand. 1993 vol. 64, nr. 6 p. 654-6</ref>.  
*no postsecondary education, older age, female gender, history of previous neck pain, baseline neck pain intensity greater than 55/100, presence of neck pain at baseline, presence of headache at baseline, catastrophising, WAD grade 2 or 3, and no seat belt in use at the time of collision<ref>Walton D.M. (2009). Risk Factors for Persistent Problems Following Whiplash Injury: Results of a Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 39(5), pp. 334–350.</ref>.<ref name=":38" />
*history of previous neck pain, baseline neck pain intensity greater than 55/100, presence of neck pain at baseline, presence of headache at baseline, catastrophising, WAD grade 2 or 3, and no seat belt in use at the time of collision<ref>Walton D.M. (2009). Risk Factors for Persistent Problems Following Whiplash Injury: Results of a Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 39(5), pp. 334–350.</ref>.<ref name=":38" />
*If the patient was out of work before the accident, sick-listed, or had social assistance, this can also be associated with a negative evolution following whiplash trauma. Illness notification before the accident can also be associated with neck pain in the future<ref name=":2" />.
*If the patient was out of work before the accident, sick-listed, or had social assistance<ref name=":2" />.
*Baseline disability has a strong association with chronic disability, but psychological and behavioural factors are also important<ref>Williamson E. et al. (2015). Risk factors for chronic disability in a cohort of patients with acute whiplash-associated disorders seeking physiotherapy treatment for persisting symptoms. Physiotherapy., 101(1), pp.34-43</ref>.  
*Baseline disability has a strong association with chronic disability, but psychological and behavioural factors are also important<ref>Williamson E. et al. (2015). Risk factors for chronic disability in a cohort of patients with acute whiplash-associated disorders seeking physiotherapy treatment for persisting symptoms. Physiotherapy., 101(1), pp.34-43</ref>.  
*Cold pain threshold, neck ROM, headache, posttraumatic stress symptoms, hyperarousal symptoms (PDS), initial high Neck Disability Index (NDI)<ref name=":38" />  
*Cold pain threshold, neck ROM, headache, posttraumatic stress symptoms, hyperarousal symptoms (PDS), initial high Neck Disability Index (NDI)<ref name=":38" />  


== Whiplash Clinical Prediction Rule ==
== Whiplash Clinical Prediction Rule ==
A Clinical Prediction Rule (CPR) is a tool that helps to predict outcome for example the possibility of a person to have moderate/severe pain and disability or have full recovery after a whiplash injury.<ref name=":38" /> CPRs are used mostly in the following circumstances:<ref name=":38" />
A Clinical Prediction Rule (CPR) is a tool that helps to predict the outcome, for example, the possibility of a person to have moderate/severe pain and disability or have full recovery after a whiplash injury.<ref name=":38" /> CPRs are used mostly in the following circumstances:<ref name=":38" />
* complex decision-making
* Complex decision-making
* uncertainty
* Uncertainty
* cost saving possibilities with no compromise to patient care
* Cost-saving possibilities with no compromise to patient care
According to Howell, chronic neck pain following a whiplash-type injury could be predicted with the use of the Neck Disability Index (NDI). She found correlations with pain, disability and driving task scores with whiplash associated disorder (WAD) patients. Also, she reported that active cervical range-of-motion (CROM) reductions were common and important clinical outcome measures related to clinical prognosis of neck disability<ref>Howell ER. The association between neck pain, the Neck Disability Index and cervical ranges of motion: a narrative review. ''J Can Chiropr Assoc.'' 2011 Sep; 55(3): 211–221. Available from: ''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154067/pdf/jcca-v55-3-211.pdf www.ncbi.nlm.nih.gov/pmc/articles/PMC3154067/pdf/jcca-v55-3-211.pdf]''</ref>
 
The CPR for WAD suggests the following:<ref name=":38" />
The CPR for WAD suggests the following:<ref name=":38" />
* Probability for chronic moderate/severe disability with older age (≥35), initial high levels of neck disability (NDI≥40) and symptoms of hyperarousal
* Probability for chronic moderate/severe disability with older age (≥35), initial high levels of neck disability (NDI≥40) and symptoms of hyperarousal
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[https://www.google.com/imgres?imgurl=https%3A%2F%2Fars.els-cdn.com%2Fcontent%2Fimage%2F1-s2.0-S0304395913003679-gr2.jpg&imgrefurl=https%3A%2F%2Fwww.sciencedirect.com%2Fscience%2Farticle%2Fpii%2FS0304395913003679&docid=zt09KEyZerTE2M&tbnid=de0Nfn_QgmGEIM%3A&vet=1&w=578&h=376&client=firefox-b-1-ab&bih=1006&biw=1920&ved=2ahUKEwjL7M6frYPaAhVNba0KHdV2DlcQxiAoAXoECAAQFQ&iact=c&ictx=1 Clinical Prediction Rule Algorithm]
[https://www.google.com/imgres?imgurl=https%3A%2F%2Fars.els-cdn.com%2Fcontent%2Fimage%2F1-s2.0-S0304395913003679-gr2.jpg&imgrefurl=https%3A%2F%2Fwww.sciencedirect.com%2Fscience%2Farticle%2Fpii%2FS0304395913003679&docid=zt09KEyZerTE2M&tbnid=de0Nfn_QgmGEIM%3A&vet=1&w=578&h=376&client=firefox-b-1-ab&bih=1006&biw=1920&ved=2ahUKEwjL7M6frYPaAhVNba0KHdV2DlcQxiAoAXoECAAQFQ&iact=c&ictx=1 Clinical Prediction Rule Algorithm]


Ritchie et al found this CPR to be reproducible and accurate when used following whiplash due to a motor vehicle collision<ref>Ritchie C, Hendrikz J, Jull G, Elliott J, Sterling M. External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. journal of orthopaedic & sports physical therapy. 2015 Apr;45(4):242-50. Available from: http://www.journalofphysiotherapy.com/article/S1836-9553(16)00015-1/fulltext [Accessed 23 March 2018]</ref>  
Ritchie et al found this CPR to be reproducible and accurate when used following whiplash due to a motor vehicle collision<ref>Ritchie C, Hendrikz J, Jull G, Elliott J, Sterling M. External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. journal of orthopaedic & sports physical therapy. 2015 Apr;45(4):242-50. Available from: http://www.journalofphysiotherapy.com/article/S1836-9553(16)00015-1/fulltext [Accessed 23 March 2018]</ref> Kelly et al explored the agreement between physiotherapists' prognostic risk classification with those of the whiplash CPR and found that the agreement was very low. Physiotherapists tended to be "overly optimistic" about patient outcomes. Kelly et al therefore suggest that the CPR may be beneficial for physiotherapists when assessing patients with whiplash.<ref>Kelly J, Ritchie C, Sterling M. Agreement is very low between a clinical prediction rule and physiotherapist assessment for classifying the risk of poor recovery of individuals with acute whiplash injury. Musculoskelet Sci Pract. 2019;39:73-9. </ref>  


== Clinical Presentation ==
== Clinical Presentation ==
Whiplash-associated disorders, is a complex condition with varied disturbances in motor, sensorimotor, and sensory functions and psychological distress<ref name=":10">Elliott et al. (2009). Characterization of acute and chronic whiplash-associated disorders. Journal of orthopaedic &amp; sports physical therapy, 39(5), pp. 312-323</ref><ref>Erbulut DU. (2014). Biomechanics of neck injuries resulting from rear-end vehicle collisions. Turk. Neurosurg., 24(4), pp. 466-470</ref>. The most common symptoms are sub-occipital headache and/or neck pain that is constant or motion-induced<ref name=":11">Ferrari R. et al. (2005). A re-examination of the whiplash associated disorders (WAD) as a systemic illness. Ann Rheum Dis., 64, pp. 1337-1342</ref>.  There may be up to 48 hrs delay of symptom onset from the initial injury<ref name=":12">Delfini R. et al. (1999). Delayed post-traumatic cervical instability. Surg Neurol.,51 Pp.588-595.</ref>.
Whiplash-associated disorder is a complex condition with varied disturbances in motor, sensorimotor, and sensory functions and psychological distress<ref name=":10">Elliott et al. (2009). Characterization of acute and chronic whiplash-associated disorders. Journal of orthopaedic &amp; sports physical therapy, 39(5), pp. 312-323</ref><ref>Erbulut DU. (2014). Biomechanics of neck injuries resulting from rear-end vehicle collisions. Turk. Neurosurg., 24(4), pp. 466-470</ref>. The most common symptoms are sub-occipital headache and/or neck pain that is constant or motion-induced<ref name=":11">Ferrari R. et al. (2005). A re-examination of the whiplash associated disorders (WAD) as a systemic illness. Ann Rheum Dis., 64, pp. 1337-1342</ref>.  There may be up to 48 hrs delay of symptom onset from the initial injury<ref name=":12">Delfini R. et al. (1999). Delayed post-traumatic cervical instability. Surg Neurol.,51 Pp.588-595.</ref>.


=== Motor dysfunction: ===
'''Motor Dysfunction'''
*One of the most common clinical characteristics is a restricted range of motion of the cervical spine. This finding may reflect underlying disturbances in motor function due to the initial peripheral nociceptive input caused by injured anatomical cervical structures. Further research of such potential mechanisms in WAD is necessary<ref name=":0" /><ref name=":10" />.  
*Restricted range of motion of the cervical spine. <ref name=":0" /><ref name=":10" />.  
*Another characteristic is altered patterns of muscle recruitment in both the cervical spine and shoulder girdle regions. This is clearly shown to be a feature of chronic WAD<ref name=":10" /><ref name=":20">Sterling M. (2004). A proposed new classification system for whiplash associated disorders-implications for assessment and management. Man Ther., 9(2), pp. 60-70.</ref><ref name=":21">Sterling M. et al. (2006). Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain, 122, pp.102-108</ref><ref name=":28">Suissa et al. (2001). The relation between initial symptoms and signs and the prognosis of whiplash. Eur Spine J. 10, pp. 44-49. </ref>.  
*Altered patterns of muscle recruitment in both the cervical spine and shoulder girdle regions (clearly a feature of chronic WAD)<ref name=":10" /><ref name=":20">Sterling M. (2004). A proposed new classification system for whiplash associated disorders-implications for assessment and management. Man Ther., 9(2), pp. 60-70.</ref><ref name=":21">Sterling M. et al. (2006). Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain, 122, pp.102-108</ref><ref name=":28">Suissa et al. (2001). The relation between initial symptoms and signs and the prognosis of whiplash. Eur Spine J. 10, pp. 44-49. </ref>.  
*Mechanical cervical spine instability<ref name=":12" />  
*Mechanical cervical spine instability<ref name=":12" />  
 
'''Sensorimotor Dysfunction''' (Greater in patients who also report dizziness due to the neck pain<ref name=":10" /><ref name=":29">Sturzenegger M. et al. (1994). Presenting symptoms and signs after whiplash injury: The influence of accident mechanisms. Neurol., 44, pp. 688–693 </ref><ref name=":27">Van Goethem J. et al. Spinal Imaging: Diagnostic Imaging of the Spine and Spinal Cord. p 258 </ref><ref>Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502.</ref>)
=== Sensorimotor dysfunction ===
*Loss of balance
*Loss of balance
*Disturbed neck influenced eye movement control<ref name=":12" />  
*Disturbed neck influenced eye movement control<ref name=":12" />  
*Sensorimotor dysfunction is greater in patients who also report dizziness due to the neck pain<ref name=":10" /><ref name=":29">Sturzenegger M. et al. (1994). Presenting symptoms and signs after whiplash injury: The influence of accident mechanisms. Neurol., 44, pp. 688–693 </ref><ref name=":27">Van Goethem J. et al. Spinal Imaging: Diagnostic Imaging of the Spine and Spinal Cord. p 258 </ref>.
'''Sensory Dysfunction: Sensory Hypersensitivity to a Variety of Stimuli'''
 
=== Sensory dysfunction: sensory hypersensitivity to a variety of stimuli ===
* Psychological distress
* Psychological distress
* Post traumatic stress<ref name=":10" />  
* Post-traumatic stress<ref name=":10" />  
* Concentration and memory problems<ref name=":29" /><ref name=":27" />  
* Concentration and memory problems<ref name=":29" /><ref name=":27" /><ref>Beeckmans K, Crunelle C, Van Ingelgom S, Michiels K, Dierckx E, Vancoillie P et al. Persistent cognitive deficits after whiplash injury: a comparative study with mild traumatic brain injury patients and healthy volunteers. Acta Neurol Belg. 2017;117(2):493-500. </ref>  
* Sleep disturbances<ref name=":Daenen">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 </ref>
* Sleep disturbances<ref name=":Daenen">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 </ref>
* Anxiety<ref name=":29" />
* Anxiety<ref name=":29" />
* Depression<ref name=":29" /> is common in WAD patients. There are different types we can distinguish:
* Depression<ref name=":29" />  
** Initial depression: this can be associated with greater neck and low back pain severity, numbness/tingling in arms/hands, vision problems, dizziness, fracture<ref name=":22">Phillips LA. Et al. (2010). Whiplash-associated disorders: who gets depressed? Who stays depressed?. Eur. Spine J., 19(6), pp. 945-956 </ref>
** Initial depression: associated with greater neck and low back pain severity, numbness/tingling in arms/hands, vision problems, dizziness, fracture<ref name=":22">Phillips LA. Et al. (2010). Whiplash-associated disorders: who gets depressed? Who stays depressed?. Eur. Spine J., 19(6), pp. 945-956 </ref>
** Persistent depression: this can be associated with older age, greater initial neck and low back pain, post-crash dizziness, anxiety, numbness/tingling, vision and hearing problems<ref name=":22" />  
** Persistent depression: associated with older age, greater initial neck and low back pain, post-crash dizziness, anxiety, numbness/tingling, vision and hearing problems<ref name=":22" />  
 
'''Degeneration of Cervical Muscles'''
=== Degeneration cervical muscles ===
* Neck stiffness<ref name=":29" /><ref name=":27" />  
* Neck stiffness<ref name=":29" /><ref name=":27" />  
* Fatty infiltrate may be present in the deep muscles in the suboccipital region and the multifidi may account for some of the functional impairments such as: Proprioceptive deficits, Balance loss, Disturbed motor control of the neck<ref name=":3">BINDER A., The diagnosis and treatment of nonspecific neck pain and whiplash, Eura Medicophys 2007, vol. 43, nr. 1, p. 79-89. </ref><ref name=":11" /><ref name=":20" /><ref name=":21" /><ref name=":29" /><ref name=":28" /><ref name=":27" />  
* Fatty infiltrate may be present in the deep muscles in the suboccipital region and the multifidi may account for some of the functional impairments such as: Proprioceptive deficits, Balance loss, Disturbed motor control of the neck<ref name=":3">BINDER A., The diagnosis and treatment of nonspecific neck pain and whiplash, Eura Medicophys 2007, vol. 43, nr. 1, p. 79-89. </ref><ref name=":11" /><ref name=":20" /><ref name=":21" /><ref name=":29" /><ref name=":28" /><ref name=":27" />  
'''Other Symptoms'''


=== Other Symptoms ===
The following symptoms may also occur<ref name=":12" /><ref name=":29" />  
The following symptoms may also occur<ref name=":12" /><ref name=":29" />  
*Tinnitus
*Tinnitus
Line 118: Line 114:
*Thoracic, temporomandibular, facial, and limb pain
*Thoracic, temporomandibular, facial, and limb pain


It is important to carry out thorough spinal and neurological examinations in patients with WAD to screen for delayed onset of the cervical spine instability or myelopathy<ref name=":12" />. Whiplash can be an acute or chronic disorder. In acute whiplash, symptoms last no more than 2-3 months, while in chronic whiplash symptoms last longer than three months. Patients with acute WAD experience widespread pressure hypersensitivity and reduced cervical mobility<ref name=":13">Fernandez Perez AM. et al. (2012). Muscle trigger points, pressure pain threshold, and cervical range of motion in patients with high level of disability related to acute whiplash injury, J. Orthop. Sports Phys. Ther.,42(7), pp. 634-641</ref>. [23 [LOE :2B]] Various studies indicate that there can be a spontaneous recovery within 2-3 months<ref>Gargan MF. Et al. (1994).The rate of recovery following whiplash injury. Eur Spine J, 3, pp. 162</ref>  According to the Quebec Task Force of WAD (QTF-WAD), 85% of the patients recover within 6 months<ref name=":4">Bekkering GE. et al., KNGF-richtlijn: whiplash. Nederlands tijdschrift voor fysiotherapie nummer 3/jaargang 11</ref>.   
It is important to carry out thorough spinal and neurological examinations in patients with WAD to screen for delayed onset of the cervical spine instability or myelopathy<ref name=":12" />. Whiplash can be an acute or chronic disorder. In acute whiplash, symptoms last no more than 2-3 months, while in chronic whiplash symptoms last longer than three months. Patients with acute WAD experience widespread pressure hypersensitivity and reduced cervical mobility<ref name=":13">Fernandez Perez AM. et al. (2012). Muscle trigger points, pressure pain threshold, and cervical range of motion in patients with high level of disability related to acute whiplash injury, J. Orthop. Sports Phys. Ther.,42(7), pp. 634-641</ref>. Various studies indicate that there can be a spontaneous recovery within 2-3 months<ref>Gargan MF. Et al. (1994).The rate of recovery following whiplash injury. Eur Spine J, 3, pp. 162</ref>  According to the Quebec Task Force of WAD (QTF-WAD), 85% of the patients recover within 6 months<ref name=":4">Bekkering GE. et al., KNGF-richtlijn: whiplash. Nederlands tijdschrift voor fysiotherapie nummer 3/jaargang 11</ref>.   


In addition, according to a follow-up study by Crutebo et al. (2010), some symptoms were already transient at baseline and symptoms such as neck pain, reduced cervical range of motion, headache, and low back pain, decreased further over the 6 months period. They also investigated the prevalence of depression and found that at baseline this was around 5% in both women and men, whereas post traumatic stress and anxiety were more common in women (19.7% and 11.7%, respectively) compared to men (13.2% and 8.6%). The majority of all reported associated symptoms were mild at both baseline and during follow-up<ref>Crutebo S. et al. (2010). The course of symptoms for whiplash-associated disorders in Sweden: 6-month followup study. J. Rheumatol., 37(7), pp. 1527-33</ref>.
In addition, according to a follow-up study by Crutebo et al. (2010), some symptoms were already transient at baseline and symptoms such as neck pain, reduced cervical range of motion, headache, and low back pain, decreased further over the 6 months period. They also investigated the prevalence of depression and found that at baseline this was around 5% in both women and men, whereas post traumatic stress and anxiety were more common in women (19.7% and 11.7%, respectively) compared to men (13.2% and 8.6%). The majority of all reported associated symptoms were mild at both baseline and during follow-up<ref>Crutebo S. et al. (2010). The course of symptoms for whiplash-associated disorders in Sweden: 6-month followup study. J. Rheumatol., 37(7), pp. 1527-33</ref>.


== Classification ==
== Evaluation ==
The Canadian cervical spine rules or NEXUS criteria are useful for the evaluation of cervical spine injuries in the emergency department. These criteria determine the need for imaging based on the mechanism of injury, physical presentation at the time of the accident, symptomatic presentation in the emergency department, as well as the physical exam. 
* The NEXUS c-spine criteria recommend imaging if there is posterior midline cervical-spine tenderness,  focal deficits,  altered mental status,  intoxication or distracting injuries.
* The Canadian c-spine rules define the need for imaging with patients greater than 65 years of age, dangerous mechanism of injury, paresthesia, midline tenderness, immediate onset of neck pain and impaired range of motion. 
Additional imaging such as MRI may be necessary for abnormal findings on CT to evaluate for cord injury.  Flexion and extension films can help rule out ligamentous injury<ref name=":41" />


=== QTFC (Quebec Task Force Classification)<ref name=":27" /> ===
== Clinical Diagnosis ==
The Quebec Task Force was a task force sponsored by a public insurer in Canada. This Task Force developed recommendations regarding the classification and treatment of WAD, which were used to develop a guide for managing whiplash in 1995.  An updated report was published in 2001. Each of the QTFC grades corresponds to a specific treatment recommendation<ref name=":20" />.<br>  
WAD can be diagnosed based on the mechanism of the injury and clinical presentation of the patient, <ref name=":20" /><ref name=":23">Rodriquez A. et al. (2004). Whiplash: pathophysiology, diagnosis, treatment, and prognosis. Muscle Nerve, 29, pp. 768-81. </ref>.  There are no specific neuropsychological tests that can diagnose WAD<ref name=":23" />. However, there are several psychological symptoms, as described above, that are associated with WAD. In addition, a whiplash profile has been developed with high scores on sub-scales of somatisation, [[depression]] and obsessive-compulsive behaviour in patients with WAD<ref name=":1" />.


{| width="404" cellspacing="1" cellpadding="1" border="1" align="center"
=== Differential Diagnosis ===
|-
Includes:  
| '''QTFC Grade'''
* Cervical spine fracture,  
| '''Clinical presentation'''
* Carotid artery dissection,  
|-
* Herniated disc,  
| 0'''<br>'''
* Spinal cord injury,  
|
* Subluxation of the cervical spine,  
*No complaint about neck pain
* Muscle strain,  
*No physical signs
* Facet injury,  
|-
* Ligamentous injury.   
| I<br>
== Outcome Measures  ==
|
*Neck complaints of pain, stiffness or tenderness only
*No physical signs
|-
| II<br>
|
*Neck complaint
*Musculoskeletal signs including
**decreased ROM
**point tenderness
|-
| <span style="font-weight: bold;">III</span><br>
|
*Neck complaint
*Musculosceletal signs
*Neurological signs including:  
**decreased or absent deep tendon reflexes
**muscle weakness
**sensory deficits
|-
| IV<br>
|
*Neck complaint and fracture or dislocation
|}
<br>
 
=== MQTFC (Modified Quebec Task Force Classification)<ref name=":20" /> ===
{| width="404" cellspacing="1" cellpadding="1" border="2" align="center"
|-
|
'''Proposed<br> classification grade'''
 
|''' Physical and psychological impairments present<br>'''
|-
| WAD 0<br>
|
*No complaints about neck pain
*No physical signs
|-
| WAD I<br>
|
*'''No&nbsp;complaints of pain, stiffness or tenderness only'''
*No physical signs
|-
| WAD IIA<br>
|
*Neck complaint
*'''Motor impairment'''
**decreased ROM
**altered muscle recruitment patterns (CCFT)
*'''Sensory Impairment'''
**local cervical mechanical hyperalgesia
|-
| WAD IIB<br>
|
*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<br>
|
*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<br>
|
*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 post traumatic stress (IES)
|-
| WAD IV
| '''Fracture or dislocation'''
|}
 
<br>
 
=== Radanov et al Classification<ref name=":37" /> ===
In addition, a classification based on subjective complaints and formal testing of self-estimated cognitive impairment, divided attention, and speed of information processing was suggested by Radanov and co-workers<ref name=":37">Radanov BP. Et al. (1992). Cognitive deficits in patients after soft tissue injury of the cervical spine. Spine, 17, pp. 127–131 </ref>
 
*Lower cervical spine syndrome (LCS) accompanied by cervical and cervicobrachial pain.
*Cervicoencephalic syndrome (CES) characterized by headache, fatigue, dizziness, poor concentration, disturbed accommodation, and impaired adaptation to light intensity.
 
In comparison with the QTF classification, this system of classification incorporates neuropsychological symptoms<ref>Sterner Y. and Gerdle B. (2004). Acute and chronic whiplash disorders - a review. J Reabil Med 2004; 36: 193–210</ref>.
 
== Differential Diagnosis ==
 
*Soft tissue lesions:
**Cervical radiculopathy<ref>CHIEN A. et al., Whiplash (grade II) and cervical radiculopathy share a similar sensory presentation: an investigation using quantative sensory testing, Clin J Pain 2008, vol. 24, nr. 7, p. 595-603.</ref>
**Cervical myelopathy<ref name=":3" />
**[[Cervical_Arterial_Dysfunction|Vascular abnormality of cervical structures]]
*Fibromyalgia and psychogenic causes<ref name=":3" />:
**Psychogenic pain disorder
**Facticious disorder
**Malingering<ref name=":14">EVANS RW. , Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review, Headache 2010, vol. 50, nr. 4, p. 716-724. </ref>
*Mechanical lesions:
**Cervical herniated disk<ref name=":3" />
**Mechanical Neck Disorder<ref>GUO LY et al., Three-dimensional characteristics of neck movements in subjects with mechanical neck disorder, J Back Musculoskelet Rehabil., 2012, vol. 25, nr. 1, p. 47-53.</ref>
*Inflammatory:
**Inflammatory rheumatologic disease<ref name=":3" />
**[[Polymyalgia_Rheumatica|Polymyalgia Rheumatica]]<ref name=":3" />
*Metabolic<ref name=":3" />:
**[[Osteoporosis|Osteoporosis]]
**Cervical osteoarthritis
*Infective:
**Infection or [[Osteomyelitis|osteomyelitis]]<ref name=":3" />
*Malignancy:
**Tumor or malignancy of cervical spine<ref name=":3" />
*Adjacent pathology:
**Shoulder or acromioclavicular disease<ref name=":3" />
*Other:
**[[Cervicogenic_Headache|Cervicogenic Headache]]<ref>VINCENT M.B., Headache and Neck, Curr Pain Headache Rep., 2011, vol. 15, nr. 4, p. 324-331 </ref>
**[[Referred_Pain|Referred pain]] from cardiothoracic structures
**[[Traumatic_Brain_Injury|Traumatic Brain Injury]]<ref name=":14" />
 
== Diagnostic Procedures  ==
 
=== Clinical diagnosis ===
WAD can be diagnosed based on the mechanism of the injury and clinical presentation of the patient, <ref name=":20" /><ref name=":23">Rodriquez A. et al. (2004). Whiplash: pathophysiology, diagnosis, treatment, and prognosis. Muscle Nerve, 29, pp. 768-81. </ref>.  There are no specific neuropsychological tests that can diagnose WAD<ref name=":23" />. However, there are several psychological symptoms, as described above, that are associated with WAD. In addition, a whiplash profile has been developed with high scores on sub-scales of somatisation, depression and obsessive compulsive behaviour in patients with WAD<ref name=":1" />.
 
=== Radiographic diagnosis ===
Whiplash injury is most often not identified radiologically in the acute phase<ref name=":30">Yalda S. et al. (2008). Whiplash: diagnosis, treatment, and associated injuries, Curr. Rev. Muscoloskelet. Med., 1(1), pp. 65-68 </ref> . The most common radiographic findings are<ref>Eck JC. Et al. Whiplash: a review of a commonly misunderstood injury., Am J Med., 2001;110:651–6. </ref>:
 
*preexisting degenerative disease
*slight loss of the normal lordotic curve of the cervical spine
*kyphotic angle at the time of injury due to hypermobility and secondary to muscle spasm
 
MRI is not indicated at the time of initial presentation because of the high false positive results<ref name=":31">Van Goethem J. et al., Whiplash injuries: is there a role for imaging?, Eur J Radiol., 1996;22:30–37.</ref>.
 
CT and MRI are generally used by patients with suspected spinal cord or disc injury, fracture or ligamentous injury. They may also be indicated in patients with long term persistent arm pain, neurological deficits, or clinical signs of nerve root compression<ref name=":31" />
 
X-ray should be routinely used for the patients with WAD grade III and IV. If the X-ray gives positive results for fracture or dislocation, the patient should be immediately referred to an emergency department or to a specialist surgeon<ref name=":6" />. 
 
[[Canadian_C-Spine_Rule|Canadian C-Spine Rule]] (CCR) is an algorithm to determine the necessity for cervical spine radiography in alert and stable patients with trauma and cervical spine injury<ref name=":32">Stiell IG et al., The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma., N Engl J Med., 2003;349(26): 2510-2518. </ref>. 
 
== Outcome measures ==
* [[Neck_Disability_Index|Neck Disability Index]]<ref name=":4" /><ref>Vernon H. The neck disability index: patient assessment and outcome monitoring in whiplash. Journal of Muskuloskeletal Pain 1996 vol. 4(4): 95-104</ref><ref name=":33">Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders: Clinical resource guide, TRACsa: Trauma and Injury Recovery, South Australia, Adelaide 2008, p. 46-69.</ref><ref name=":33" />
* [[Neck_Disability_Index|Neck Disability Index]]<ref name=":4" /><ref>Vernon H. The neck disability index: patient assessment and outcome monitoring in whiplash. Journal of Muskuloskeletal Pain 1996 vol. 4(4): 95-104</ref><ref name=":33">Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders: Clinical resource guide, TRACsa: Trauma and Injury Recovery, South Australia, Adelaide 2008, p. 46-69.</ref><ref name=":33" />
* [[Visual_Analogue_Scale|Visual Analogue Scale]] (VAS)<ref name=":4" /><ref name=":33" />  
* [[Visual_Analogue_Scale|Visual Analogue Scale]] (VAS)<ref name=":4" /><ref name=":33" />  
* [[Pain Catastrophizing Scale]]  
* [[Pain Catastrophizing Scale]]  
* The Whiplash Activity a participation List (WAL)<ref>STENNEBERG MS. et al. « Validation of a new questionnaire to assess the impact of Whiplash Associated Disorders: The Whiplash Activity and participation List (WAL) » Man Ther. vol. 20, nr. 1, p. 84-89, 2015.</ref>  
* The Whiplash Activity a participation List (WAL)<ref>STENNEBERG MS. et al. « Validation of a new questionnaire to assess the impact of Whiplash Associated Disorders: The Whiplash Activity and participation List (WAL) » Man Ther. vol. 20, nr. 1, p. 84-89, 2015.</ref>  
* Disabilities of the Arm, Shoulder and Hand (DASH) in persistent Whiplash<ref>SEE KS. “ Identifying upper limb disability in patients with persistent whiplash. “ Man Ther, vol. 20, nr. 3, p. 487-493, 2015.</ref>
* [[DASH Outcome Measure|Disabilities of the Arm, Shoulder and Hand (DASH)]] in persistent Whiplash<ref>SEE KS. “ Identifying upper limb disability in patients with persistent whiplash. “ Man Ther, vol. 20, nr. 3, p. 487-493, 2015.</ref>
* [[SF-36|SF-36]]<ref>ANGST F. et al. (2014). Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective, outcome study. BMC Musculoskelet Disord., 15, 130.</ref><ref name=":33" />  
* [[36-Item Short Form Survey (SF-36)|SF-36]]<ref>ANGST F. et al. (2014). Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective, outcome study. BMC Musculoskelet Disord., 15, 130.</ref><ref name=":33" />  
* Functional Rating Index<ref name=":33" />
* Functional Rating Index<ref name=":33" />
* The Self-Efficacy Scale<ref name=":33" />
* The Self-Efficacy Scale<ref name=":33" />
* The Coping Strategies Questionnaire<ref name=":33" />
* The Coping Strategies Questionnaire<ref name=":33" />
* [[Patient_Specific_Functional_Scale|Patient-Specific Functional Scale]]<ref name=":33" />  
* [[Patient_Specific_Functional_Scale|Patient-Specific Functional Scale]]<ref name=":33" />  
* Core Whiplash Outcome Measure<ref name=":33" />
* General Health Questionnaire (CHQ)
* The Kessler Psychological Distress Scale<ref name=":33" />
* The Impact of Event Scale<ref name=":33" />


== Examination ==
== Examination ==
Line 319: Line 154:
The assessment of individuals with WAD should follow the normal [[Cervical Examination|cervical examination]].  
The assessment of individuals with WAD should follow the normal [[Cervical Examination|cervical examination]].  


=== Subjective ===
=== Subjective ===
The subjective history should specifically include information about:  
The subjective history should specifically include information about:  


*prior history of neck problems (including previous whiplash)
*Prior history of neck problems (including a previous whiplash)
*prior history of long-term problems (injury and illness)
*Prior history of long-term problems (injury and illness)
*current psychosocial problems (family, job-related, financial)
*Current psychosocial problems (family, job-related, financial)
*symptoms (location + time of onset)
*Symptoms (location + time of onset)
*mechanism of injury (e.g. sport, motor vehicle)
*Mechanism of injury (e.g. sport, motor vehicle)
 
=== Outcome Measures ===
#General Health Questionnaire (CHQ)
#Visual Analogue pain Scale
#Neck Disability index


=== Objective ===
=== Objective ===
Physical examination is required to identify signs and symptoms and classify WAD according to the QTF-WAD<ref name=":34">Sterling M. (2014). Physiotherapy management of whiplash-associated disorders (WAD). Journal of Physiotherapy, 60, pp. 5–12</ref>.
Physical examination is required to identify signs and symptoms and classify WAD according to the QTF-WAD<ref name=":34">Sterling M. (2014). [https://www.sciencedirect.com/science/article/pii/S1836955314000058 Physiotherapy management of whiplash-associated disorders (WAD).] Journal of Physiotherapy, 60, pp. 5–12 Available from: https://www.sciencedirect.com/science/article/pii/S1836955314000058 (last accessed 2.2.2020)</ref>.
 
Inspection and palpation.  


During palpation, stiffness and tenderness of the muscles may be observed. These physical symptoms are present in grade 1, 2 and 3. Trigger points may also be observed in grade 2 and 3 WAD. The number of active trigger points may be related to higher neck pain intensity, the number of days since the accident, higher pressure pain hypersensitivity over the cervical spine, and reduced active cervical range of motion<ref name=":13" />.<br> <br>ROM testing.  
==== Inspection and Palpation ====
During palpation, stiffness and tenderness of the muscles may be observed. These physical symptoms are present in grade 1, 2 and 3. Trigger points may also be observed in grade 2 and 3 WAD. The number of active trigger points may be related to higher neck pain intensity, the number of days since the accident, higher pressure pain hypersensitivity over the cervical spine, and reduced active cervical range of motion<ref name=":13" />.  


In grade 1 WAD, there are no physical signs, so there will be no decreased ROM. In grades 2 and 3, a decreased ROM can be identified by testing the neck flexion, extension, rotation and 3D movements<ref name=":13" /><ref name=":34" />.<br> <br>Neurological examination
==== ROM Testing ====
In grade 1 WAD, there are no physical signs, so there will be no decreased ROM. In grades 2 and 3, a decreased ROM can be identified by testing the neck flexion, extension, rotation and 3D movements<ref name=":13" /><ref name=":34" />.


To distinguish grade 3 from grade 2, neurological examination is needed. Patients with grade 3 have symptoms of hypersensitivity to a variety of stimuli. These can be subjectively reported by patients, and may include allodynia, high irritability of pain, cold sensitivity, and poor sleep due to pain.
==== Neurological Examination ====
To distinguish grade 3 from grade 2, a neurological examination is needed. Patients with grade 3 have symptoms of hypersensitivity to a variety of stimuli. These can be subjectively reported by patients, and may include allodynia, high irritability of pain, cold sensitivity, and poor sleep due to pain.


Objectively, the results of the neurological examination are hyporeflection, decreased muscles force and sensory deficits in dermatome and myotome. These responses may occur independently of psychological distress. Other physical tests for hypersensitivity include pressure algometers, pain with the application of ice, or increased bilateral responses to the brachial plexus provocation test.
Objectively, the results of the neurological examination are hyporeflection, decreased muscles force and sensory deficits in dermatome and myotome. These responses may occur independently of psychological distress. Other physical tests for hypersensitivity include pressure algometers, pain with the application of ice, or increased bilateral responses to the brachial plexus provocation test.


It is important to know that these neurological symptoms do not necessarily indicate peripheral nerve compression and may be a reflection of altered central nociceptive processes<ref name=":34" />.
== Management ==
 
* Education, resumption of normal activity, and mobilization exercises are generally the treatment of choice. 
These findings may be important for the differential diagnosis of acute whiplash injury. A poorer outcome is generally predicted in patients with higher initial pain and disability as well as hypersensitivty (e.g. cold hyperalgesia)<ref name=":34" /><ref>Sterling M. et al. (2004). Characterization of acute whiplash-associated disorders. Spine (Phila Pa 1976)., 29(2), pp. 182-188. </ref>.<br> <br>“In recent years, there has also been extensive research undertaken demonstrating movement, muscle, and motor control changes in the neck and shoulder girdles of patients with neck pain, including WAD. Study findings include inferior performance on tests of motor control involving the cervical flexor, extensor and scapular muscle groups when compared to asymptomatic control participants; changes in muscle morphology of the cervical flexor and extensor muscles; loss of strength and endurance of cervical and scapular muscle groups; and sensorimotor changes manifested by increased joint re-positioning errors, poor kinaesthetic awareness, altered eye movement control, and loss of balance. Detailed information on the clinical assessment of cervical motor function is available elsewhere. The rationale for the evaluation of such features is to plan an individualised exercise program for each patient based on the assessment findings.” <ref name=":34" />.
* Ultrasound has also been shown to relieve muscle pain for whiplash-associated disorders.  
 
* First-line treatments include analgesics, nonsteroidal anti-inflammatories, ice, and heat.  
== Medical Management ==
* Other controversial analgesic measures include muscle relaxants, which have been shown to have some therapeutic effect in limited studies.   
 
* Biofeedback has also demonstrated effectiveness when used in conjunction with other modalities in acute WAD. 
=== Steroid injections ===
* Injection of lidocaine intramuscularly was also found to relieve pain symptoms. 
The cervical facet joint can be a source of pain in individuals with chronic WAD. Animal studies have demonstrated that cervical facet joint injury may be responsible for hypersensitivity and increased neuronal excitability.<br>Pain from the cervical facet joint can be medically managed using steroid injections to the specific zygopopsyal joints. Steroid injections can be used to treat acute and chronic WAD. However, the there are conflicting findings on the possible outcomes from such treatment<ref>Barnsley L. et al. “Lack of Effect of Intraarticular Corticosteroids for Chronic Pain in the Cervical Zygapophyseal Joints” N Engl J Med., vol. 330, p. 1047-1050, 1994 .</ref><ref name=":5">Conlin A. et al. Treatment of whiplash-associated disorders-part II: Medical and surgical interventions: Pain Res Manag. 2005, vol. 10, nr. 1, p. 33-40. </ref><ref name=":25">Pettersson K. et al. “High-dose methylprednisolone prevents extensive sick leave after whiplash injury. A prospective, randomized, double-blind study” Spine, vol. 23, nr 9, p. 984-9, 1998.</ref> [45 [LOE :1B]] [15 [LOE:1A]].<br>Pettersson et al. suggests that a high dose of methyl-prednisolone therapy given to the patient within 8h after injury minimises the chance of developing chronic WAD. It is not often used because of the practical difficulties of this treatment (8h limitation, 23-h infusion, need for hospitalisation, cost)<ref name=":25" /> [45 [LOE :1B]].
* Most treatments alone appeared to have moderate effectiveness with combinations of treatment measures improving efficacy and early mobilization consistently most effective<ref name=":41" />
 
=== Radiofrequency neurotomy ===
The nociception input from the cervical facet joint can be modulated via radiofrequency neurotomy (RFN).<br>The radiofrequency neurotomy is a neuroablative procedure used to interrupt nociceptive pathways and uses heat generated by radio waves to target specific nerves (medial branch emitted by dorsal ramus) and temporarily interfere with their ability to transmit pain signals from the facet joints. The RNF can improve the pain, disability widespread hyperalgesia to pressure and thermal stimuli, nociceptive flexor reflex threshold, and brachial plexus provocation responses as well as increased neck range of motion one month and up to 3 months after the RFN<ref>Smith AD. Et al. Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash: Pain Med. 2014 vol. 15, nr. 1, p. 128-41.</ref>. [55 [LOE :4]] A prospective study with chronic WAD patients who underwent CRFN treatment, showed an improvement in 70% of patients based on a number of parameters including Neck Disability Index and cervical range of motion<ref>Prushansky T. et al. (2006). Cervical radiofrequency neurotomy in patients with chronic whiplash: a study of multiple outcome measures. J Neurosurg, 4(5): p.365–373. </ref><ref name=":24">Seferiadis A. et al. (2004). A review of treatment interventions in whiplash-associated disorders, Eur Spine J, 13 : 387–397 </ref> [47 [LOE :3B]] [54 [LOE :1A]]
 
=== Botulin toxin treatment ===
Botulinum Toxin-A (BTX-A) decreases muscle spasm that contribute to both pain and dysfunction. Pain and range of motion with patients with chronic grade 2 WAD improves 2 to 4 weeks post treatment<ref>Freund BJ. Et al. « Treatment of whiplash associated neck pain with botulinum toxin-A: a pilot study » J Rheumatol., vol. 27, nr. 2, p. 481-4, 2000.</ref><ref>Baker JA and Pereira G, The efficacy of Botulinum Toxin A for spasticity and pain in adults: a systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation approach, Clin Rehabil 2013, vol. 27, nr. 12, p. 1084-1096.</ref> [27 [LOE: 1B]]. [85 [LOE: 1A]<br>The effect of the Botulinum toxin lasts nearly 8-12 weeks. Most patients treated with Botulinum toxin require repeated injections over many years<ref>Nigam PK. and Nigam A.. BOTULINUM TOXIN. Indian J Dermatol: 2010. vol. 55, nr. 1, p. : 8–14.</ref>. [44 [LOE :5]]<br>Other interventions are sterile water injections, saline injections, dextrose, lidocaine intra-articular injections and epidural blood patch therapy. However, it is not clear whether these treatments are actually beneficial. Further research is required to determine the efficacy and the role of invasive interventions in the treatment of chronic WAD<ref>Teasell RW. et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 5 – surgical and injection-based interventions for chronic WAD. Pain res manag: 2010. vol. 15, nr. 5, p. 323-334.</ref> [72 [LOE:1A]].
 
=== Surgical interventions ===
A study by Jonsson et al. (1994) found that 20% of patients had a protrusion of a cervical disc of grade 3 or grade 4 on MRI which correlated with neurological findings after a whiplash injury<ref>Jonsson H. et al. “Findings and outcome in whiplash-type neck distortions.” Spine, vol. 19, p. 2733-43, 1994.</ref>.  Such patients might need to undergo anterior cervical discectomy<ref name=":6" />.  After the discectomy, the surgeon might need to permanently stabilise the cervical spine. This can be achieved using artificial cervical disc or fusion of the cervical vertebrae<ref>Motor accidents authority (2001). Guidelines for Management of Whiplash-Associated Disorders: 8.</ref>.  
 
Cervical discectomy and anterior cervical fusion can also be used to treat chronic WAD if the non-invasive treatments (including multimodal physical therapy) did not provide satisfactory results<ref name=":5" />. Indications for surgery include severe and prolonged headache, neck and radicular pain if the symptoms identified during the clinical examination are in agreement with the radiographic findings<ref name=":2" />.


== Physical Management  ==
== Physical Management  ==
The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this approach is advocated in current clinical guidelines.<ref name=":34" />
* Management approaches for patients with WAD are poorly researched.
* Often patients do not fit into treatment categories due to multiple factors, and multiple variances which warrant individualised treatment approaches<ref name=":21" />.
* Whiplash-associated disorder is a debilitating and costly condition of at least 6-month duration. 
* The majority of patients with whiplash show no physical signs<ref name=":15">Meeus M. et al. Pain Physician. The efficacy of patient education in whiplash associated disorders: a systematic review. 2012 Sep-Oct;15(5):351-61.</ref> however as many as 50% of victims of WAD grade 1 & 2 will still be experiencing chronic neck pain and disability six months later. A substantial minority  develop LWS (late whiplash syndrome), i.e. persistence of significant symptoms beyond 6 months after injury<ref name=":16">Lamb SE. Et al. MINT Study Team. Managing Injuries of the Neck Trial (MINT): design of a randomised controlled trial of treatments for whiplash associated disorders. BMC Musculoskelet Disord. 2007 Jan 26;8:7</ref>. 
* The combination of the injury with psychological factors eg poor coping style may lead to chronic WAD<ref name=":24">Seferiadis A. et al. (2004). A review of treatment interventions in whiplash-associated disorders, Eur Spine J, 13 : 387–397 </ref>.


Management approaches for patients with WAD are poorly researched. Very often these patients 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 individualised treatment approaches<ref name=":21" />.(LOE: 2b)
=== Acute Whiplash ===
 
Education provided by physiotherapists or general practitioners is important in preventing chronic whiplash and must be part of the biopsychosocial approach for whiplash patients. The most important goals of the interventions are:  
Whiplash-associated disorder is a debilitating and costly condition of at least 6-month duration. Although the majority of patients with whiplash show no physical signs<ref name=":15">Meeus M. et al. Pain Physician. The efficacy of patient education in whiplash associated disorders: a systematic review. 2012 Sep-Oct;15(5):351-61.</ref>,(LOE: 1a), studies have shown that as many as 50% of victims of whiplash injury (grade 1 or 2 WAD) will still be experiencing chronic neck pain and disability six months later. In most cases, symptoms are short lived. Only a substantial minority goes on to develop LWS (late whiplash syndrome), i.e. persistence of significant symptoms beyond 6 months after injury<ref name=":16">Lamb SE. Et al. MINT Study Team. Managing Injuries of the Neck Trial (MINT): design of a randomised controlled trial of treatments for whiplash associated disorders. BMC Musculoskelet Disord. 2007 Jan 26;8:7</ref>.(LOE: 1b) Available data suggest that the combination of the injury with psychological factors such as coping style and explanatory style may lead to chronic WAD<ref name=":24" />.(LOE: 1a)
 
=== Acute whiplash  ===
 
Treatment for acute whiplash can be delayed due to multiple social, economic, and psychological factors<ref name=":30" />.(LOE: 1a) Psychological factors such as depression, anxiety, expectations for recovery, and high psychological distress have been identified as important prognostic factors for WAD patients<ref name=":15" />.(LOE: 1a)
 
Coping strategies such as diverting attention and increasing activity are related to positive outcomes<ref name=":15" />.(LOE: 1a) Another review with a high evidence level recommends that patients suffering from acute WAD “act as usual” and do early, controlled, physical activity within their tolerance level<ref name=":24" />(LOE: 1a)<ref name=":34" />.(LOE: 5)
 
Education provided by physiotherapists or general practitioners is important in preventing of chronic whiplash, and must be part of the biopsychosocial approach for whiplash patients. The most important goals of the interventions are:


#Reassuring the patient
#Reassuring the patient
#Modulating maladaptive cognition about WAD
#Modulating maladaptive cognition about WAD
#Activating the patient<ref name=":15" />(LOE: 1a)
#Activating the patient<ref name=":15" />
* The target of education is removing therapy barriers, enhancing therapy compliance and preventing and treating chronicity<ref name=":15" />.
* For acute WAD verbal education and written advice are helpful (evidence exists that oral information is equally as efficient as an active exercise program)<ref name=":15" />.
* A multidisciplinary programme is best for subacute/chronic patients, with a programme integrating information, exercises and behavioural programmes.
<br>Different types of education include<ref name=":15" />:


The target of education is removing therapy barriers, enhancing therapy compliance and preventing and treating chronicity<ref name=":15" />.(LOE: 1a)
#'''Oral Education''': Provide oral education concerning the whiplash mechanisms and emphasising [[Physical Activity and Exercise Prescription|physical activity]] and correct posture. It has a better effect on [[Pain Behaviours|pain]], cervical mobility, and recovery, compared to rest and neck collars. Oral education could be as effective as active physiotherapy and mobilisation.
#'''Educational video''': A brief psycho-educational video shown at the patient's bedside seems to have a profound effect on subsequent pain and medical utilisation in acute whiplash patients, compared to the usual care<ref name=":17">Gross A. et al. Patient education for neck pain. COCHRANE DATABASE OF SYSTEMATIC REVIEWS. 2012;3</ref><ref name=":15" /><ref name=":35">Teasell RW. Et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2 – interventions for acute WAD. Pain Res Manage 2010;15(5):295-304</ref>.


There is strong evidence that to reduce pain, disability and improve mobility both verbal education and written advice are helpful. According to Meeus et al., in acute patients oral information is equally as efficient as an active exercise program<ref name=":15" />.(LOE: 1a) <br>In subacute or chronic patients, a programme integrating information, exercises and behavioural programmes, and a multidisciplinary programme, seem necessary. For more information on this refer to the section on chronic WAD.<br>In acute whiplash patients, a short oral education session is effective in reducing pain and enhancing mobility and recovery. Different types of education include<ref name=":15" />:(LOE: 1a)
Education and information given to the patient must contain the following information:
 
#'''Oral Education''': there is strong evidence for providing oral education concerning the whiplash mechanisms and emphasising physical activity and correct posture. It has abetter effect on pain, cervical mobility, and recovery, compared to rest and neck collars. Furthermore, studies show that oral education could be as effective as active physiotherapy and mobilisation.
#'''Educational video''': A brief psycho-educational video shown at the patient's bedside seems to have a profound effect on subsequent pain and medical utilisation in acute whiplash patients, compared to the usual care<ref name=":17">Gross A. et al. Patient education for neck pain. COCHRANE DATABASE OF SYSTEMATIC REVIEWS. 2012;3</ref>(LOE: 1a)<ref name=":15" />(LOE: 1a)<ref name=":35">Teasell RW. Et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2 – interventions for acute WAD. Pain Res Manage 2010;15(5):295-304</ref>.(LOE: 1a)
 
According to the Whiplash book education and information given to the patient must contain the following information:


*Reassurance that prognosis following a whiplash injury is good.
*Reassurance that prognosis following a whiplash injury is good.
*Encouragement to return to normal activities as soon as possible using exercises to facilitate recovery
*Encouragement to return to normal activities as soon as possible using exercises to facilitate recovery
*Reassurance that pain is normal following a whiplash injury and that patients should use analgesia consistently to control this
*Reassurance that pain is normal following a whiplash injury and that patients should use analgesia consistently to control this
*Advice against using a soft collar<ref name=":16" />(LOE: 1b)
*Advice against using a soft collar<ref name=":16" /> as exercises and/or advice to stay active has shown more favourable outcomes on pain and disability<ref>Christensen SW, Rasmussen MB, Jespersen CL, Sterling M, Skou ST. [https://www.sciencedirect.com/science/article/abs/pii/S2468781221001107 Soft-collar use in rehabilitation of whiplash-associated disorders-A systematic review and meta-analysis.] Musculoskeletal Science and Practice. 2021 Oct 1;55:102426.</ref>


More studies are required to provide firm evidence for the type, duration, format, and efficacy of education in the different types of whiplash patients<ref name=":15" />(LOE: 1a)<ref name=":35" />(LOE: 1a)
More studies are required for the type, duration, format, and efficacy of education in the different types of whiplash patients<ref name=":15" /><ref name=":35" />.


Future research should be founded on sound adult learning theory and learning skill acquisition<ref name=":17" /> (LOE: 1a)<br> <br>Different types of exercise can be considered for WAD, including ROM exercises, McKenzie exercises, postural exercises, and strengthening and motor control exercises. It is not clear which type of exercise is more effective or if specific exercise is more effective than general activity or merely advice to remain active<ref name=":34" /> (LOE: 5)<br> <br>Active treatment which consists of early active mobilisation that is applied gently and over a small ROM, and which is repeated 10 times in each direction every waking hour seems to be as effective at reducing the pain after the whiplash injury as on ROM. This exercise can also be given as homework<ref name=":26">Rosenfeld M. et al.(2000). Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine, vol. 25, nr. 14, p. 1782-7. </ref> (LOE: 2b)<br> <br>In a randomised study by A. Söderlund et al., where the aim was to compare two different home exercise programs in acute WAD, the result was that a home exercise programme, including training of neck and shoulder ROM, relaxation and general advice, seems to be sufficient treatment for acute WAD patients when used on a daily basis<ref>Söderlund A. et al. (2000). Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clin Rehabil. 4(5):457-67.</ref>.(LOE: 1b)<br> <br>Supported by several high and low quality studies, evidence-based therapy for acute WAD consists of early physical activity, mobilisation and education.
Different types of exercise can be considered for WAD
* [[Range of Motion|ROM exercises,]]
* [[McKenzie Method|McKenzie]] exercises
* [[Posture|Postural]] exercises
* [[Strength and Conditioning|Strengthening]]
* [[Motor Control and Learning|Motor control exercises.]]
Active treatment which consists:
* Active mobilisation that is applied gently and over a small ROM, and which is repeated 10 times in each direction, also be given as [[Adherence to Home Exercise Programs|homework]]<ref name=":26">Rosenfeld M. et al.(2000). Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine, vol. 25, nr. 14, p. 1782-7. </ref>


From this, we can conclude that there is strong evidence to suggest that exercise programs and active mobilisation significantly reduce pain in the short term and there is evidence that mobilisation may also improve ROM<ref>Bonk AD. Et al. (2000). Prospective, randomised, controlled study of activity versus collar, and the natural history for whiplash injury, in Germany. World Congress on Whiplash-Associated Disorders in Vancouver, British Columbia, Canada, February 1999. J Musculoskel Pain 8: 123–132</ref>(LOE: 1b)<ref>Conlin A. et al. (2005). Treatment of whiplash-associated disorders-part I: Non-invasive interventions. Pain Res Manag 10(1):21-32.</ref>(LOE: 1a)<ref>McKinney LA. (1989). Early mobilisation and outcome in acute sprains of the neck. BMJ 299:1006–1008,</ref>(LOE: 1b)<ref>Rosenfeld M. et al.(2003). Active intervention in patients with whiplash-associated disorders improves long-term prognosis. A randomised controlled trial. Spine 28:2491–2498 </ref>(LOE: 1b)<ref name=":26" />(LOE: 2b)<ref name=":35" />.(LOE: 1a) <br> <br>Spinal manual therapy is often used in the clinical management of neck pain. It is not easy to tease out the effects of manual therapy alone because most studies used it as part of a multimodal package of treatment.
* Home exercise programs in acute WAD including training of neck and shoulder ROM, relaxation and general advice, is sufficient treatment for acute WAD patients when used on a daily basis<ref>Söderlund A. et al. (2000). Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clin Rehabil. 4(5):457-67.</ref>.


Systematic reviews of the few trials that have assessed manual therapy techniques alone concluded that manual therapy, such as passive mobilisation, applied to the cervical spine may provide some benefit in reducing pain, but that the included trials were of low quality<ref name=":34" />.(LOE: 5)<br> <br>Patients with grades 1 and 2 2 WAD showed good results in a multimodal treatment program including exercises and group therapy, manual therapy, education and exercise. At their 6 months follow-up, 65% of subjects reported a complete return to work, 92% reported a partial or complete return to work, and 81% reported no medical or paramedical treatments over 6 months<ref>Vendrig A. et al. (2000). Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck. Spine, 25 (2): p.238–244 (4)</ref>(LOE: 4)
* Strong evidence to suggest that exercise programs and active mobilisation significantly reduce pain in the short term and there is evidence that mobilisation may also improve ROM<ref>Bonk AD. Et al. (2000). Prospective, randomised, controlled study of activity versus collar, and the natural history for whiplash injury, in Germany. World Congress on Whiplash-Associated Disorders in Vancouver, British Columbia, Canada, February 1999. J Musculoskel Pain 8: 123–132</ref><ref>Conlin A. et al. (2005). Treatment of whiplash-associated disorders-part I: Non-invasive interventions. Pain Res Manag 10(1):21-32.</ref><ref>McKinney LA. (1989). Early mobilisation and outcome in acute sprains of the neck. BMJ 299:1006–1008,</ref><ref>Rosenfeld M. et al.(2003). Active intervention in patients with whiplash-associated disorders improves long-term prognosis. A randomised controlled trial. Spine 28:2491–2498 </ref><ref name=":26" /><ref name=":35" />.


For the early management of WAD grades 1 and 2, general practitioner care includes advice to stay active and resumption of regular activities.
* Spinal manual therapy is often used in the clinical management of neck pain. Systematic reviews of the few trials that have assessed manual therapy techniques alone concluded that manual therapy, such as passive mobilisation, applied to the cervical spine may provide some benefit in reducing pain,<ref name=":34" />.


The synthesis of DA Sutton et al. suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD<ref name=":32" />.(LOE: 2b)
* Patients with grades 1 and 2  WAD showed good results in a multimodal treatment program including exercises and group therapy, manual therapy, education and exercise. At their 6 months follow-up, 65% of subjects reported a complete return to work, 92% reported a partial or complete return to work, and 81% reported no medical or paramedical treatments over 6 months<ref>Vendrig A. et al. (2000). Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck. Spine, 25 (2): p.238–244 (4)</ref>


Another interesting topic is the use of a collar. The use of a collar stands in contrast with what is indicated in most of the studies; activation, mobilisation and exercise. In a randomised study of Bonk et al. subjects were randomly assigned to a collar therapy group or to the exercise group. During a one week period participants had to record their average pain and disability in a diary, using the VAS scale. The results showed a significant difference between the groups, with positive effects on the prevalence of symptoms in the exercise therapy group compared to the collar group at six weeks. It is proven that early exercise therapy is superior to collar therapy in reducing pain intensity and disability for whiplash injury. Other studies also showed that exercise therapy gives a better pain relief than a soft collar<ref name=":26" />(LOE: 2b)<ref>Schnabel M.et al. (2004). Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury. Emerg Med J 21:306-310</ref>(LOE: 1b)<ref name=":35" />.(LOE: 1a) <br>
* The use of a collar stands in contrast with what is indicated in most of the studies; activation, mobilisation and exercise. It is proven that early exercise therapy is superior to collar therapy in reducing pain intensity and disability for whiplash injury. Other studies also showed that exercise therapy gives better pain relief than a soft collar<ref name=":26" /><ref>Schnabel M.et al. (2004). Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury. Emerg Med J 21:306-310</ref><ref name=":35" />. <br>
 
=== Chronic Whiplash  ===
 
There is a difference between a patient suffering from acute whiplash and a patient suffering from chronic whiplash. There is a suggestion that the injury in combination with psychological factors may lead to chronic WAD<ref name=":24" />.(LOE: 1a)
 
A multidisciplinary therapy with cognitive, behavioural therapy and physical therapy, including neck exercises is effective in the management of WAD patients with chronic neck pain<ref>Hansen IR. et al. Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: design of a randomised controlled trial. BMC musculoskelet disord. 2011; 12 </ref>LOE: 1b)<ref name=":24" />(LOE: 1a)<ref name=":36">TEASELL RW. Et al., A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD, Pain Res Manag 2010, vol. 15, nr. 5, p. 313-322.</ref>(LOE: 1a)
 
When behavioural therapy is used in the therapy, it decreases the patient’s pain intensity in problematic daily activities. Therefore functional behavioural analyses can be used to adapt planning and treatment<ref>SÖDERLUND A. and LINDBERG P., An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic whiplash associated disorders, WAD, Disabil Rehabil 2001, vol. 23, nr. 10, p. 436-447. </ref>.(LOE: 4)
 
There is evidence that exercise programs have a positive result in reducing pain in the short term. Exercise programmes are the most effective noninvasive treatment for patients with chronic WAD, although many questions remain regarding the relative effectiveness of various exercise regimens. There is also evidence suggesting that coordination exercises should be added to the treatment to reduce neck pain.
 
Multidisciplinary therapy gives positive results according to the reductions of neck pain and sick leave reported<ref name=":24" />(LOE: 1a).
 
This is also the therapy recommended by the Dutch clinical guidelines for WAD<ref>van der Wees PJ. Et al . Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review. AustJPhysiother 2008,54(4):233-241.(1)</ref>.(LOE: 1a)<br> <br>In patients with chronic WAD, negative thoughts are a very important factor. Self-efficacy, a measure of how well an individual believes he can perform a task or specific behaviour and emotional reaction in stressful situations, was the most important predictor of persistent disability in those patients<ref>Bunketorp L et al. (2006). The perception of pain and pain related cognition in subacute whiplash-associated disorders: its influence on prolonged disability. Disabil Rehabil, 28(5): p.271–279 (2)</ref>.(LOE: 1b)
 
Negative thoughts and pain behaviour can be influenced by specialists and physical therapists by educating patients with chronic WAD on the neurophysiology of pain. Improvement in pain behaviour resulted in improved neck disability and increased pain-free movement performance and pain thresholds according to a pilot study<ref>Van Oosterwijck J. et al. (2011). Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study, Journal of rehabilitation research and development, (48) nr.1: p43-58 (3) </ref>.(LOE: 4)
 
Michaleff et al. even found that simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme<ref name=":18">Michaleff ZA. et al., Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial, Lancet. 2014 Jul 12; 384(9938):133-41.</ref>.(LOE: 1b)
 
In a case report of Ferrantelli J.R.et al., the patient underwent a Clinical Biomechanics of Posture Rehabilitation in which he received mirror-image cervical spine adjustments, exercises and traction to reduce head protrusion and cervical kyphosis. The first ten visits included regional bilateral long-lever cervical spinal manipulation to temporarily decrease pain and increase ROM, and there after the structural rehabilitation care started. This treatment consisted in mirror-image drop table adjustments, mirror-image handheld instrument adjustments, mirror-image isometric exercise and mirror-image extension-compression traction for the reduction of the abnormal anterior translation posture of the head. After 5 months, the patient’s chronic WAD symptoms were improved<ref>FERRANTELLI J.R. et al., Conservative Treatment of a patient With Previously Unresponsive Whiplash-Associated Disorders Using Clincal Biomechanics of Posture Rehabilitation Methods, J Manupulative Physiol Ther. 2005, vol. 28, nr. 3, p. 1-8.</ref>.(LOE: 5)
 
As Michaleff et al. say in their article, that we can conclude that an important health priority is the need to identify effective and affordable strategies to prevent and treat acute to chronic whiplash associated disorders<ref name=":18" />.(LOE: 1b)
 
=== Summary ===
Below is a listing of the various therapy techniques and studies with key evidence.<br>
 
<u>'''EVIDENCE CONCERNING IMMOBILIZATION'''</u><br>
 
{| width="100%" cellspacing="1" cellpadding="1" border="1"
|-
| '''AUTHOR'''
| '''CONCLUSION'''
| '''LEVEL'''
|-
| Quebec Task Force 1988 <ref name="Soder">Söderlund A, Olerud C, Lindberg P. Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clin Rehabil. 2000 Oct;14(5):457-67. LEVEL 2B</ref>
| Prolonged immobilization may increase scar tissue in the neck and reduce cervical mobility&nbsp;
| 2B<br>
|-
| Mealey et al 1986 <ref name="Mealy">Mealy K, Brennan H, Fenelon GC. Early mobilization of acute whiplash injuries. Br Med J Clin Res Ed). 1986 Mar 8;292(6521):656-7. LEVEL 3A</ref>
| Initial immobilization after whiplash injuries gave rise to prolonged symptoms. A more rapid improvement can be achieved by early active management without any consequent increase in discomfort
| 3A
|-
| Borchgrevink GE et al <br>2008 <ref name="Binder"/>
| Advice to “act as usual” plus NSAIDs significantly improved some symptoms (including pain during daily activities, neck stiffness, memory, concentration, and headache) after 6 months compared with immobilisation plus 14 days' sick leave plus NSAIDs&nbsp;
| 1A<br>
|-
| Teasell R.W. et al <br>2010&nbsp;<ref name="Teasell">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 Res Manag. 2010 Sep-Oct;15(5):295-304. LEVEL 1A</ref>
| Immobilization with a soft collar is less effective than active mobilization and no more effective than advice to act as usual. Active mobilization is associated with reduced pain intensity and limited evidence that mobilization may also improve ROM, although it is not clear whether active mobilization is any more effective than advice to act as usual.
| 1A<br>
|}
 
<u>'''EVIDENCE CONCERNING THE USE OF (SOFT) COLLAR'''</u><br>
 
{| width="100%" cellspacing="1" cellpadding="1" border="1"
|-
| '''AUTHOR'''
| '''CONCLUSION'''
| '''LEVEL'''
|-
| Schnabel et al 2004 <ref name="Schnabel">Schnabel M, Ferrari R, Vassiliou T, Kaluza G. Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury. Emerg Med J. 2004 May;21(3):306-10. LEVEL 2B</ref>
| Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury&nbsp;
| 2B
|-
| Binder A. 2008 <ref name="Binder"/>
| Instruction on mobilization exercises may be more effective than a soft collar at reducing pain at 6 weeks in people treated within 48 hours of a whiplash injury who all also took NSAIDs 
| 1A<br>
|-
| Schnabel M et al 2008&nbsp;<ref name="Binder"/>
| Exercises significantly reduce the proportion of people with neck pain at 6 weeks compared with a soft collar and significantly reduce pain and disability at 6 weeks
| 1A
|}
 
<u>'''EVIDENCE CONCERNING THE ADVICE TO “ACT AS NORMAL”'''</u><br>
 
{| width="100%" cellspacing="1" cellpadding="1" border="1"
|-
| '''AUTHOR'''
| '''CONCLUSION'''
| '''LEVEL'''
|-
| Binder A 2008 <ref name="Binder"/>
| Advice to "act as usual" plus NSAIDs may be more effective at 6 months than immobilization plus 14 days sick leave plus NSAIDs at improving neck stiffness in people with acute whiplash&nbsp;
| 1A<br>
|-
| Borchgrevink GE et al 2008 <ref name="Binder"/>
| Advice to “act as usual” plus NSAIDs significantly improved some symptoms (including pain during daily activities, neck stiffness, memory, concentration, and headache) after 6 months compared with immobilisation plus 14 days' sick leave plus NSAIDs&nbsp;
| 1A<br>
|-
| Yadla S et al <br>2008 <ref name="S">Yadla S, Ratliff JK, Harrop JS. Whiplash: diagnosis, treatment, and associated injuries. Curr Rev Musculoskelet Med. 2008 Mar;1(1):65-8. LEVEL 1A</ref>
| Early mobilization and return to activity may offer the best chance for recovery.
| 1A<br>
|-
| Teasell R.W. et al <br>2010 <ref name="Teasell"/>
| It does not appear that providing educational information during the acute phase provides a significant measurable benefit. There is some indication that oral and/or video presentation of educational information may be more effective than the distribution of pamphlets.
| 1A<br>
|}
 
<u>'''EVIDENCE CONCERNING PHYSICAL THERAPY'''<br></u>
 
<u></u>
 
{| width="100%" cellspacing="1" cellpadding="1" border="1"
|-
| '''AUTHOR'''
| '''DISCUSSION'''
| '''LEVEL'''
|-
| Verhagen AP 2008 <ref name="Binder"/>
| <u></u>Limited evidence that active and passive interventions seemed more effective than no treatment. Less convincing evidence about active interventions compared with passive ones&nbsp;<u></u>
| 1A
|-
| Binder A 2008 <ref name="Binder"/>
| <u></u>Instruction on mobilization exercises may be more effective than a soft collar at reducing pain at 6 weeks in people treated within 48 hours of a whiplash injury who all also took NSAIDs&nbsp;
| 1A
|-
| Lamb S et al 2013 <ref name="Gates">Lamb SE, Gates S, Williams MA, Williamson EM, Mt-Isa S, Withers EJ, Castelnuovo E, Smith J, Ashby D, Cooke MW, Petrou S, Underwood MR; Managing Injuries of the Neck Trial (MINT) Study Team. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. Lancet. 2013 Feb 16;381(9866):546-56. LEVEL 2A</ref>
| <u></u>Physiotherapy is recommended by several clinical guidelines. Recommended treatments include manual therapy, exercise, advice, and recognition of anxiety and psychological problems<u>&nbsp;</u>
| 2A
|-
| Schnabel M et al 2008&nbsp;<ref name="Binder"/>
| <u></u>Exercises significantly reduced the proportion of people with neck pain at 6 weeks compared with a soft collar and significantly reduced pain and disability at 6 weeks<u>&nbsp;</u>
| 1A
|-
| Scholten – Peeters G et al 2008&nbsp;<ref name="Binder"/>
| No significant difference between physiotherapy (exercise or mobilization) and usual care in pain intensity, headache, or work activities measured at 8, 12, 26, or 52 weeks<u></u>
| 1A
|-
| Söderlund A 2008 <ref name="Binder"/>
| No significant difference between a regular exercise regimen versus the same exercise regimen plus instructions in disability or pain after 3 or 6 months <u><br></u>
| 1A
|-
| Binder A <br>2008 <ref name="Binder">Binder AI. Neck pain. Clin Evid (Online). 2008 Aug 4;2008. LEVEL 1A</ref>
| Multimodal treatment (postural training, psychological support, eye fixation exer- cises, and manual treatment) may be more effective at improving pain at 1 and 6 months in people with whiplash due to a road traffic accident in the previous 2 months&nbsp;
| 1A
|-
| Teasell R.W. et al <br>2010&nbsp;<ref name="Teasell"/>
| Exercise programs are significantly more effective in reducing pain intensity over both the short and medium term. Conversely, supplemental exercise programs added to mobilization programs may not be any more beneficial than mobilization programs alone
| 1A
|-
| Drescher K et al <br>2008&nbsp;<ref name="Drescher">Drescher K, Hardy S, Maclean J, Schindler M, Scott K, Harris SR. Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Physiother Can. 2008 Summer;60(3):215-23      LEVEL 1A</ref>
| Moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders. <br>No evidence exists to support the use of postural exercises for increasing neck range of motion. <br>Conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders.
| 1A<br>
|}


=== Chronic Whiplash ===
* [[Chronic neck pain|Chronic]] WAD results from a combination of the injury with psychological factors <ref name=":24" /><ref>Aarnio M, Fredrikson M, Lampa E, Sörensen J, Gordh T, Linnman C. [https://journals.lww.com/pain/Fulltext/2022/03000/Whiplash_injuries_associated_with_experienced_pain.11.aspx <nowiki>Whiplash injuries associated with experienced pain and disability can be visualized with [11C]-D-deprenyl positron emission tomography and computed tomography</nowiki>]. Pain. 2022 Mar;163(3):489.</ref>
* Chronic WAD patients report worse health than people with non-specific chronic neck pain<ref>Landén Ludvigsson, M., Peterson, G. and Peolsson, A., 2019. [https://link.springer.com/article/10.1007/s11136-018-2004-3 The effect of three exercise approaches on health-related quality of life, and factors associated with its improvement in chronic whiplash-associated disorders: analysis of a randomized controlled trial]. ''Quality of Life Research'', ''28''(2), pp.357-368.</ref>
* A [[Multidisciplinary Care in Pain Management|multidisciplinary therapy]] with cognitive, behavioural therapy and physical therapy, including neck exercises is applied in management of  Chronic WAD patients.<ref>Hansen IR. et al. Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: design of a randomised controlled trial. BMC musculoskelet disord. 2011; 12 </ref><ref name=":24" /><ref name=":36">TEASELL RW. Et al., A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD, Pain Res Manag 2010, vol. 15, nr. 5, p. 313-322.</ref> <ref>Björsenius V, Löfgren M, Stålnacke BM. [https://www.mdpi.com/1660-4601/17/13/4784/htm One-Year Follow-Up after Multimodal Rehabilitation for Patients with Whiplash-Associated Disorders.] International Journal of Environmental Research and Public Health. 2020 Jul;17(13):4784.</ref> It also gives positive results according to the reductions of neck pain and sick leave.<ref name=":24" />.
* Behavioural therapy is used in the therapy as it decreases the patient’s pain intensity in problematic daily activities. ie adapt planning and treatment<ref>SÖDERLUND A. and LINDBERG P., An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic whiplash associated disorders, WAD, Disabil Rehabil 2001, vol. 23, nr. 10, p. 436-447. </ref>.
* Exercise programs have a positive result in reducing pain in the short term. Exercise programmes are the most effective noninvasive treatment for patients with chronic WAD and coordination exercises should be added to the treatment to reduce neck pain.
* In patients with chronic WAD, negative thoughts are a very important factor. <ref>Bunketorp L et al. (2006). The perception of pain and pain related cognition in subacute whiplash-associated disorders: its influence on prolonged disability. Disabil Rehabil, 28(5): p.271–279 (2)</ref>. Negative thoughts and pain behaviour can be influenced by specialists and physical therapists by educating patients with chronic WAD on the [[Pain Neuroscience Education (PNE)|neurophysiology of pain]].<ref>Van Oosterwijck J. et al. (2011). Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study, Journal of rehabilitation research and development, (48) nr.1: p43-58 (3) </ref>.
* Simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme<ref name=":18">Michaleff ZA. et al., Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial, Lancet. 2014 Jul 12; 384(9938):133-41.</ref>.
* In a study Clinical Biomechanics of [[Posture]] Rehabilitation using  mirror-image cervical spine adjustments, exercises and traction to reduce head protrusion and cervical kyphosis. After 5 months, the patient’s chronic WAD symptoms were improved<ref>FERRANTELLI J.R. et al., Conservative Treatment of a patient With Previously Unresponsive Whiplash-Associated Disorders Using Clincal Biomechanics of Posture Rehabilitation Methods, J Manupulative Physiol Ther. 2005, vol. 28, nr. 3, p. 1-8.</ref>.<u></u><u></u><u></u><u></u><u></u><u></u><u></u>
== Clinical Bottom Line ==
== Clinical Bottom Line ==
Whiplash associated disorders (WAD) are a result of a previous whiplash injury and has a variety of characteristics and symptoms. This clinical presentation can be divided into different grades, reported by The Quebec Task Force. This classification is widely used and gives recommendations about the possible therapy. When a patient has a WAD several anatomical tissues can be affected, depending on the force and direction of the impact. Some people are more likely to develop WAD than others. To diagnose WAD radiographic images are not the norm, unless it concerns a WAD Grade III and IV. It’s more useful to make a clinical diagnosis based on the clinical presentation and anamnesis. Depending on severity of the WAD different medical/surgical interventions are needed. The most common interventions are steroid injections, radiofrequency neurotomy, botulin toxin treatment, cervical discectomy and cervical fusion. Although there are a lot of medical interventions, a WAD can also be treated in a conservative way. The therapy of an acute whiplash should consist of education, where it’s made clear by the therapist to stay active and ‘act as usual’, and early physical activity and mobilization. For the management of chronic whiplash there is strong evidence that a multidisciplinary therapy is effective. This therapy also has to consist of an exercise program.
* For the management of chronic whiplash, there is strong evidence that multidisciplinary therapy is effective. This therapy consists of an exercise program. Early mobilization is most effective when other more serious clinical pathologies noted on examination and imaging diagnostics have been ruled out.
* Prognosis varies secondary to comorbidities prior to the injury, severity of WAD, age and socioeconomic environment.  Full recovery has been shown to occur in a few days to several weeks. However, disability can be permanent and range from chronic pain to impaired physical function.
* Though cervical pain is the most common symptom, dizziness and/or [[headache]]<nowiki/>s can be chronic, persistently reported symptoms. Chronic pain, subsequent interference with work, and physical function can cause loss of income and lifestyle.
* Diagnosis and treatment of WAD are complex and associated with many complex issues.  Legal environment, prior injury, comorbidity, age, and defensive medicine all play roles in the management and outcomes.  There is a large variation in diagnosis and persistence of symptoms depends largely on legal culture or the ability to seek compensation for WAD.<ref name=":41" />


== Resources ==
== Resources ==
In 2017 Walton and Elliot proposed a new Integrated Model of Chronic WAD.  This journal article will explain more on this model:
In 2017 Walton and Elliot proposed a new Integrated Model of Chronic WAD.  This journal article will explain more on this model
# Walton DM, Elliott JM. [https://www.jospt.org/doi/pdf/10.2519/jospt.2017.7455 An integrated model of chronic whiplash-associated disorder]. journal of orthopaedic & sports physical therapy. 2017 Jul;47(7):462-71.  
 
Walton DM, Elliott JM. [https://www.jospt.org/doi/pdf/10.2519/jospt.2017.7455 An integrated model of chronic whiplash-associated disorder]. journal of orthopaedic & sports physical therapy. 2017 Jul;47(7):462-71.
== References  ==
== References  ==
[[Category:Cervical Conditions]]
[[Category:Cervical Spine - Conditions]]
 
<references />
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Course Pages]]
[[Category:Plus Content]]
[[Category:Cervical Spine]]
[[Category:Course Pages]]

Latest revision as of 07:15, 18 November 2022

Original Editor - Hannah Norton

Top Contributors - Kim Jackson, Rachael Lowe, Okebanama Nelson Onyebuchi, Lucinda hampton, Admin, Tarina van der Stockt, Hannah Norton, Van Horebeek Erika, Sigrid Bortels, Steffen Kistmacher, Anouck Leo, WikiSysop, Rucha Gadgil, 127.0.0.1, Wanda van Niekerk, Jess Bell, Olajumoke Ogunleye, Robin Tacchetti, Joshua Samuel, Ine Van de Weghe and Simisola Ajeyalemi  

Definition/Description[edit | edit source]

Whiplash associated disorders (WAD) is the term used to described injuries sustained as a result of sudden acceleration-deceleration movements. It is considered the most common outcome after "noncatastrophic" motor vehicle accidents.[1] The term WAD is often used synonymously with the term Whiplash however whiplash refers to the mechanism of injury rather than the presence of symptoms such as pain, stiffness, muscle spasm and headache, in the absence of a lesion or structural pathology.[2][3] The prognosis of WAD is unknown and unpredictable, some cases remain acute with a full recovery while some progress to chronic with long term pain and disability[3] Early intervention recommendations are rest, pain relief and basic stretching and stretching exercises.[3]

The short video below sums up WAD nicely

[4]

Clinically Relevant Anatomy[edit | edit source]

Whiplash and whiplash-associated disorders (WAD) affect a variety of anatomical structures of the cervical spine, depending on the force and direction of impact as well as many other factors[5][6][7]. Causes of pain can be any of these tissues, with the strain injury resulting in secondary oedema, haemorrhage, and inflammation:

Whiplash Injuries.jpg

Pathology[edit | edit source]

Most WADs are considered to be minor soft tissue-based injuries without evidence of fracture. 

The injury occurs in three stages:  

  • Stage 1: the upper and lower spines experience flexion in stage one
  • Stage 2: the spine assumes an S-shape while it begins to extend and eventually straighten to make the neck lordotic again.
  • Stage 3: shows the entire spine in extension with an intense sheering force that causes compression of the facet joint capsules.

Studies with cadavers have shown the whiplash injury is the formation of the S-shaped curvature of the cervical spine which induced hyperextension on the lower end of the spine and flexion of the upper levels, which exceeds the physiologic limits of spinal mobility. 

The Quebec Task Force classifies patients with WAD (whiplash), based on the severity of signs and symptoms, as follows: 

  1. Grade 1 the patient complains of neck pain, stiffness, or tenderness with no positive findings on physical exam. 
  2. Grade 2 the patient exhibits musculoskeletal signs including decreased range of motion and point tenderness.   
  3. Grade 3 the patient also shows neurologic signs that may include sensory deficits, decreased deep tendon reflexes, muscle weakness.
  4. Grade 4 the patient shows a fracture[8].  

Etiology[edit | edit source]

Whiplash-associated disorders describe a range of neck-related clinical symptoms following an MVA or acceleration-deceleration injury.  The pathophysiology underpinning this disorder is still not fully understood and many theories exist. Some of the symptoms are thought to be caused by injury to the following structures: 

  • Cervical Spine Facet Joint Capsule
  • The facet joints
  • Spinal ligaments
  • Nerve roots
  • Intervertebral discs
  • Cartilage
  • Paraspinal muscles causing spasms
  • Intraarticular meniscus.[8]

Epidemiology[edit | edit source]

The most common cause of WAD is MVAs, but it also occurs as a result of sporting injuries and falls. A study by Holm et al suggested that the numbers reporting symptoms has grown increasingly in recent years; in their paper published in 2008 they suggested that the incidence in North Ameria and Europe is approximately 300 per 100,000 inhabitants[9]. In the UK the introduction of the compulsory wearing of seatbelts in 1983, an initiative to save deaths on the road, actually led to an increase in the number of reported WADs in the years[10]. It is also more common in women than men with almost two-thirds of women experiencing symptoms and several studies found that women tended to a slower or incomplete recovery.compared to men[11].  

The risk that patients develop WAD after an accident with acceleration-deceleration mechanism of energy transfer of the neck depends on a variety of factors:

  • Severity of the impact, however, it is difficult to obtain objective evidence to confirm this[12].
  • Neck pain present before the accident is a risk factor for acute neck pain after collision[13].
  • Women seem to be slightly more at risk of developing WAD.
  • Age is also important; younger people (18-23) are more likely to file insurance claims and/or are at greater risk of being treated for WAD[14][15].

The number of people worldwide who suffer from chronic pain is between 2 and 58% but lies mainly between 20 and 40%[13].

  • If a patient still has symptoms 3 months after the accident they are likely to remain symptomatic for at least two years, and possibly for much longer[15].
  • 50% of people with injury from whiplash will have a full recovery,
  • 25% may have mild levels of disability and the rest moderate to severe pain and disability[16]

There are many prognostic factors that determine the evolution of WAD and the likelihood that it will evolve into chronic pain.

  • It has been found that a poor expectation of recovery, passive coping strategies, and post-traumatic stress symptoms are associated with chronic neck pain and / or disability after whiplash[17]
  • Pre-collision self-reported unspecified pain, high psychological distress, female gender and low educational level predicted future self-reported neck pain[18].
  • history of previous neck pain, baseline neck pain intensity greater than 55/100, presence of neck pain at baseline, presence of headache at baseline, catastrophising, WAD grade 2 or 3, and no seat belt in use at the time of collision[19].[16]
  • If the patient was out of work before the accident, sick-listed, or had social assistance[18].
  • Baseline disability has a strong association with chronic disability, but psychological and behavioural factors are also important[20].
  • Cold pain threshold, neck ROM, headache, posttraumatic stress symptoms, hyperarousal symptoms (PDS), initial high Neck Disability Index (NDI)[16]

Whiplash Clinical Prediction Rule[edit | edit source]

A Clinical Prediction Rule (CPR) is a tool that helps to predict the outcome, for example, the possibility of a person to have moderate/severe pain and disability or have full recovery after a whiplash injury.[16] CPRs are used mostly in the following circumstances:[16]

  • Complex decision-making
  • Uncertainty
  • Cost-saving possibilities with no compromise to patient care

The CPR for WAD suggests the following:[16]

  • Probability for chronic moderate/severe disability with older age (≥35), initial high levels of neck disability (NDI≥40) and symptoms of hyperarousal
  • Probability for full recovery with younger age (≤35) and initial low levels of neck disability (NDI≤32)

Clinical Prediction Rule Algorithm

Ritchie et al found this CPR to be reproducible and accurate when used following whiplash due to a motor vehicle collision[21] Kelly et al explored the agreement between physiotherapists' prognostic risk classification with those of the whiplash CPR and found that the agreement was very low. Physiotherapists tended to be "overly optimistic" about patient outcomes. Kelly et al therefore suggest that the CPR may be beneficial for physiotherapists when assessing patients with whiplash.[22]

Clinical Presentation[edit | edit source]

Whiplash-associated disorder is a complex condition with varied disturbances in motor, sensorimotor, and sensory functions and psychological distress[23][24]. The most common symptoms are sub-occipital headache and/or neck pain that is constant or motion-induced[25]. There may be up to 48 hrs delay of symptom onset from the initial injury[26].

Motor Dysfunction

  • Restricted range of motion of the cervical spine. [5][23].
  • Altered patterns of muscle recruitment in both the cervical spine and shoulder girdle regions (clearly a feature of chronic WAD)[23][27][28][29].
  • Mechanical cervical spine instability[26]

Sensorimotor Dysfunction (Greater in patients who also report dizziness due to the neck pain[23][30][31][32])

  • Loss of balance
  • Disturbed neck influenced eye movement control[26]

Sensory Dysfunction: Sensory Hypersensitivity to a Variety of Stimuli

  • Psychological distress
  • Post-traumatic stress[23]
  • Concentration and memory problems[30][31][33]
  • Sleep disturbances[34]
  • Anxiety[30]
  • Depression[30]
    • Initial depression: associated with greater neck and low back pain severity, numbness/tingling in arms/hands, vision problems, dizziness, fracture[35]
    • Persistent depression: associated with older age, greater initial neck and low back pain, post-crash dizziness, anxiety, numbness/tingling, vision and hearing problems[35]

Degeneration of Cervical Muscles

  • Neck stiffness[30][31]
  • Fatty infiltrate may be present in the deep muscles in the suboccipital region and the multifidi may account for some of the functional impairments such as: Proprioceptive deficits, Balance loss, Disturbed motor control of the neck[36][25][27][28][30][29][31]

Other Symptoms

The following symptoms may also occur[26][30]

  • Tinnitus
  • Malaise
  • Disequilibrium/Dizziness
  • Thoracic, temporomandibular, facial, and limb pain

It is important to carry out thorough spinal and neurological examinations in patients with WAD to screen for delayed onset of the cervical spine instability or myelopathy[26]. Whiplash can be an acute or chronic disorder. In acute whiplash, symptoms last no more than 2-3 months, while in chronic whiplash symptoms last longer than three months. Patients with acute WAD experience widespread pressure hypersensitivity and reduced cervical mobility[37]. Various studies indicate that there can be a spontaneous recovery within 2-3 months[38] According to the Quebec Task Force of WAD (QTF-WAD), 85% of the patients recover within 6 months[39].

In addition, according to a follow-up study by Crutebo et al. (2010), some symptoms were already transient at baseline and symptoms such as neck pain, reduced cervical range of motion, headache, and low back pain, decreased further over the 6 months period. They also investigated the prevalence of depression and found that at baseline this was around 5% in both women and men, whereas post traumatic stress and anxiety were more common in women (19.7% and 11.7%, respectively) compared to men (13.2% and 8.6%). The majority of all reported associated symptoms were mild at both baseline and during follow-up[40].

Evaluation[edit | edit source]

The Canadian cervical spine rules or NEXUS criteria are useful for the evaluation of cervical spine injuries in the emergency department. These criteria determine the need for imaging based on the mechanism of injury, physical presentation at the time of the accident, symptomatic presentation in the emergency department, as well as the physical exam. 

  • The NEXUS c-spine criteria recommend imaging if there is posterior midline cervical-spine tenderness,  focal deficits,  altered mental status,  intoxication or distracting injuries.
  • The Canadian c-spine rules define the need for imaging with patients greater than 65 years of age, dangerous mechanism of injury, paresthesia, midline tenderness, immediate onset of neck pain and impaired range of motion. 

Additional imaging such as MRI may be necessary for abnormal findings on CT to evaluate for cord injury.  Flexion and extension films can help rule out ligamentous injury[8]

Clinical Diagnosis[edit | edit source]

WAD can be diagnosed based on the mechanism of the injury and clinical presentation of the patient, [27][41]. There are no specific neuropsychological tests that can diagnose WAD[41]. However, there are several psychological symptoms, as described above, that are associated with WAD. In addition, a whiplash profile has been developed with high scores on sub-scales of somatisation, depression and obsessive-compulsive behaviour in patients with WAD[14].

Differential Diagnosis[edit | edit source]

Includes:

  • Cervical spine fracture,
  • Carotid artery dissection,
  • Herniated disc,
  • Spinal cord injury,
  • Subluxation of the cervical spine,
  • Muscle strain,
  • Facet injury,
  • Ligamentous injury. 

Outcome Measures[edit | edit source]

Examination[edit | edit source]

The assessment of individuals with WAD should follow the normal cervical examination.

Subjective[edit | edit source]

The subjective history should specifically include information about:

  • Prior history of neck problems (including a previous whiplash)
  • Prior history of long-term problems (injury and illness)
  • Current psychosocial problems (family, job-related, financial)
  • Symptoms (location + time of onset)
  • Mechanism of injury (e.g. sport, motor vehicle)

Objective[edit | edit source]

Physical examination is required to identify signs and symptoms and classify WAD according to the QTF-WAD[47].

Inspection and Palpation[edit | edit source]

During palpation, stiffness and tenderness of the muscles may be observed. These physical symptoms are present in grade 1, 2 and 3. Trigger points may also be observed in grade 2 and 3 WAD. The number of active trigger points may be related to higher neck pain intensity, the number of days since the accident, higher pressure pain hypersensitivity over the cervical spine, and reduced active cervical range of motion[37].

ROM Testing[edit | edit source]

In grade 1 WAD, there are no physical signs, so there will be no decreased ROM. In grades 2 and 3, a decreased ROM can be identified by testing the neck flexion, extension, rotation and 3D movements[37][47].

Neurological Examination[edit | edit source]

To distinguish grade 3 from grade 2, a neurological examination is needed. Patients with grade 3 have symptoms of hypersensitivity to a variety of stimuli. These can be subjectively reported by patients, and may include allodynia, high irritability of pain, cold sensitivity, and poor sleep due to pain.

Objectively, the results of the neurological examination are hyporeflection, decreased muscles force and sensory deficits in dermatome and myotome. These responses may occur independently of psychological distress. Other physical tests for hypersensitivity include pressure algometers, pain with the application of ice, or increased bilateral responses to the brachial plexus provocation test.

Management[edit | edit source]

  • Education, resumption of normal activity, and mobilization exercises are generally the treatment of choice. 
  • Ultrasound has also been shown to relieve muscle pain for whiplash-associated disorders.
  • First-line treatments include analgesics, nonsteroidal anti-inflammatories, ice, and heat.
  • Other controversial analgesic measures include muscle relaxants, which have been shown to have some therapeutic effect in limited studies. 
  • Biofeedback has also demonstrated effectiveness when used in conjunction with other modalities in acute WAD. 
  • Injection of lidocaine intramuscularly was also found to relieve pain symptoms. 
  • Most treatments alone appeared to have moderate effectiveness with combinations of treatment measures improving efficacy and early mobilization consistently most effective[8]

Physical Management[edit | edit source]

The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this approach is advocated in current clinical guidelines.[47]

  • Management approaches for patients with WAD are poorly researched.
  • Often patients do not fit into treatment categories due to multiple factors, and multiple variances which warrant individualised treatment approaches[28].
  • Whiplash-associated disorder is a debilitating and costly condition of at least 6-month duration.
  • The majority of patients with whiplash show no physical signs[48] however as many as 50% of victims of WAD grade 1 & 2 will still be experiencing chronic neck pain and disability six months later. A substantial minority develop LWS (late whiplash syndrome), i.e. persistence of significant symptoms beyond 6 months after injury[49].
  • The combination of the injury with psychological factors eg poor coping style may lead to chronic WAD[50].

Acute Whiplash[edit | edit source]

Education provided by physiotherapists or general practitioners is important in preventing chronic whiplash and must be part of the biopsychosocial approach for whiplash patients. The most important goals of the interventions are:

  1. Reassuring the patient
  2. Modulating maladaptive cognition about WAD
  3. Activating the patient[48]
  • The target of education is removing therapy barriers, enhancing therapy compliance and preventing and treating chronicity[48].
  • For acute WAD verbal education and written advice are helpful (evidence exists that oral information is equally as efficient as an active exercise program)[48].
  • A multidisciplinary programme is best for subacute/chronic patients, with a programme integrating information, exercises and behavioural programmes.


Different types of education include[48]:

  1. Oral Education: Provide oral education concerning the whiplash mechanisms and emphasising physical activity and correct posture. It has a better effect on pain, cervical mobility, and recovery, compared to rest and neck collars. Oral education could be as effective as active physiotherapy and mobilisation.
  2. Educational video: A brief psycho-educational video shown at the patient's bedside seems to have a profound effect on subsequent pain and medical utilisation in acute whiplash patients, compared to the usual care[51][48][52].

Education and information given to the patient must contain the following information:

  • Reassurance that prognosis following a whiplash injury is good.
  • Encouragement to return to normal activities as soon as possible using exercises to facilitate recovery
  • Reassurance that pain is normal following a whiplash injury and that patients should use analgesia consistently to control this
  • Advice against using a soft collar[49] as exercises and/or advice to stay active has shown more favourable outcomes on pain and disability[53]

More studies are required for the type, duration, format, and efficacy of education in the different types of whiplash patients[48][52].

Different types of exercise can be considered for WAD

Active treatment which consists:

  • Active mobilisation that is applied gently and over a small ROM, and which is repeated 10 times in each direction, also be given as homework[54]
  • Home exercise programs in acute WAD including training of neck and shoulder ROM, relaxation and general advice, is sufficient treatment for acute WAD patients when used on a daily basis[55].
  • Strong evidence to suggest that exercise programs and active mobilisation significantly reduce pain in the short term and there is evidence that mobilisation may also improve ROM[56][57][58][59][54][52].
  • Spinal manual therapy is often used in the clinical management of neck pain. Systematic reviews of the few trials that have assessed manual therapy techniques alone concluded that manual therapy, such as passive mobilisation, applied to the cervical spine may provide some benefit in reducing pain,[47].
  • Patients with grades 1 and 2 WAD showed good results in a multimodal treatment program including exercises and group therapy, manual therapy, education and exercise. At their 6 months follow-up, 65% of subjects reported a complete return to work, 92% reported a partial or complete return to work, and 81% reported no medical or paramedical treatments over 6 months[60]
  • The use of a collar stands in contrast with what is indicated in most of the studies; activation, mobilisation and exercise. It is proven that early exercise therapy is superior to collar therapy in reducing pain intensity and disability for whiplash injury. Other studies also showed that exercise therapy gives better pain relief than a soft collar[54][61][52].

Chronic Whiplash[edit | edit source]

  • Chronic WAD results from a combination of the injury with psychological factors [50][62]
  • Chronic WAD patients report worse health than people with non-specific chronic neck pain[63]
  • A multidisciplinary therapy with cognitive, behavioural therapy and physical therapy, including neck exercises is applied in management of Chronic WAD patients.[64][50][65] [66] It also gives positive results according to the reductions of neck pain and sick leave.[50].
  • Behavioural therapy is used in the therapy as it decreases the patient’s pain intensity in problematic daily activities. ie adapt planning and treatment[67].
  • Exercise programs have a positive result in reducing pain in the short term. Exercise programmes are the most effective noninvasive treatment for patients with chronic WAD and coordination exercises should be added to the treatment to reduce neck pain.
  • In patients with chronic WAD, negative thoughts are a very important factor. [68]. Negative thoughts and pain behaviour can be influenced by specialists and physical therapists by educating patients with chronic WAD on the neurophysiology of pain.[69].
  • Simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme[70].
  • In a study Clinical Biomechanics of Posture Rehabilitation using mirror-image cervical spine adjustments, exercises and traction to reduce head protrusion and cervical kyphosis. After 5 months, the patient’s chronic WAD symptoms were improved[71].

Clinical Bottom Line[edit | edit source]

  • For the management of chronic whiplash, there is strong evidence that multidisciplinary therapy is effective. This therapy consists of an exercise program. Early mobilization is most effective when other more serious clinical pathologies noted on examination and imaging diagnostics have been ruled out.
  • Prognosis varies secondary to comorbidities prior to the injury, severity of WAD, age and socioeconomic environment.  Full recovery has been shown to occur in a few days to several weeks. However, disability can be permanent and range from chronic pain to impaired physical function.
  • Though cervical pain is the most common symptom, dizziness and/or headaches can be chronic, persistently reported symptoms. Chronic pain, subsequent interference with work, and physical function can cause loss of income and lifestyle.
  • Diagnosis and treatment of WAD are complex and associated with many complex issues.  Legal environment, prior injury, comorbidity, age, and defensive medicine all play roles in the management and outcomes.  There is a large variation in diagnosis and persistence of symptoms depends largely on legal culture or the ability to seek compensation for WAD.[8]

Resources[edit | edit source]

In 2017 Walton and Elliot proposed a new Integrated Model of Chronic WAD. This journal article will explain more on this model

Walton DM, Elliott JM. An integrated model of chronic whiplash-associated disorder. journal of orthopaedic & sports physical therapy. 2017 Jul;47(7):462-71.

References[edit | edit source]

  1. ↑ Walton DM, Elliott JM. An Integrated Model of Chronic Whiplash-Associated Disorder. J Orthop Sports Phys Ther. 2017;47(7):462-71.
  2. ↑ Spitzer WO. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining" whiplash" and its management. Spine. 1995;20:1S-73S.
  3. ↑ 3.0 3.1 3.2 Stace R. and Gwilym S. « Whiplash associated disorder: a review of current pain concepts. » Bone & Joint 360, vol. 4, nr. 1. 2015. 
  4. ↑ 3D4Medical - Cervical Whiplash | Trauma. Available from:https://youtu.be/jgMdL7vEga8 (last accessed 22 April 2020)
  5. ↑ 5.0 5.1 Coleman T. (2014). Symptoms of whiplash neck injury, treatment for acute tinnitus, fatigue syndrome. Geraadpleegd op 26 april 2016 via http://www.tinnitusmiracle.com/Tinnitus-Miracle-Video.php?hopc2s=galus&tid=2016
  6. ↑ Graziano D.L. et al. (2007). Positive Cervical Artery Testing in a Patient with Chronic Whiplash Syndrome: Clinical Decision-Making in the Presence of Diagnostic Uncertainty. J Man Manip Ther. 15 (3), pp. 45–63.
  7. ↑ Joslin CC. et al. « Long-term disability after neck injury. A comparative study. » J Bone Joint Surg Br., vol. 86, nr. 7, p. 1032-4, 2004.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Bragg KJ, Varacallo M. Cervical (Whiplash) Sprain. InStatPearls [Internet] 2019 Apr 10. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK541016/ (last accessed 2.2.2020)
  9. ↑ Holm LW, Carroll LJ, Cassidy JD, Hogg-Johnson S, Côté P, Guzman J, Peloso P, Nordin M, Hurwitz E, van der Velde G, Carragee E. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics. 2009 Feb 1;32(2):S61-9.
  10. ↑ Minton R, Murray P, Stephenson W, Galasko CS. Whiplash injury—are current head restraints doing their job?. Accident Analysis & Prevention. 2000 Mar 1;32(2):177-85.
  11. ↑ Carroll LJ, Holm LW, Hogg-Johnson S, Côté P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, Van Der Velde G, Peloso PM. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics. 2009 Feb 1;32(2):S97-107.
  12. ↑ HOLM L.W. (2008). The Burden and Determinants of Neck Pain in Whiplash-Associated Disorders After Traffic Collisions: Results of the Bone and Joint Decade 2000 –2010 Task Force on Neck Pain and Its Associated Disorders. Eur Spine J., 17(Suppl 1), pp. 52–59.
  13. ↑ 13.0 13.1 Loppolo F. et al. (2014). Epidemiology of Whiplash-Associated Disorders. Springer-Verlag Italia.
  14. ↑ 14.0 14.1 Cassidy JD. et al. (2000). Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med., 342(16), pp. 1179-86
  15. ↑ 15.0 15.1 McClune T. et al. (2002). Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J,19, pp 499–506 
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 Ritchie C, Hendrikz J, Kenardy J, Sterling M. Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury. PAIN®. 2013 Oct 1;154(10):2198-206. Available from: http://www.udptclinic.com/journalclub/sojc/13-14/November/Ritchie%202013.pdf [Accessed 23 March 2018]
  17. ↑ Campbell L, Smith A, McGregor L, Sterling M. Psychological Factors and the Development of Chronic Whiplash-associated Disorder(s): A Systematic Review. Clin J Pain. 2018;34(8):755-68.
  18. ↑ 18.0 18.1 Algers G. et al. Surgery for chronic symptoms after whiplash injury. Follow-up of 20 cases: Acta Orthop Scand. 1993 vol. 64, nr. 6 p. 654-6
  19. ↑ Walton D.M. (2009). Risk Factors for Persistent Problems Following Whiplash Injury: Results of a Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 39(5), pp. 334–350.
  20. ↑ Williamson E. et al. (2015). Risk factors for chronic disability in a cohort of patients with acute whiplash-associated disorders seeking physiotherapy treatment for persisting symptoms. Physiotherapy., 101(1), pp.34-43
  21. ↑ Ritchie C, Hendrikz J, Jull G, Elliott J, Sterling M. External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. journal of orthopaedic & sports physical therapy. 2015 Apr;45(4):242-50. Available from: http://www.journalofphysiotherapy.com/article/S1836-9553(16)00015-1/fulltext [Accessed 23 March 2018]
  22. ↑ Kelly J, Ritchie C, Sterling M. Agreement is very low between a clinical prediction rule and physiotherapist assessment for classifying the risk of poor recovery of individuals with acute whiplash injury. Musculoskelet Sci Pract. 2019;39:73-9.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 Elliott et al. (2009). Characterization of acute and chronic whiplash-associated disorders. Journal of orthopaedic & sports physical therapy, 39(5), pp. 312-323
  24. ↑ Erbulut DU. (2014). Biomechanics of neck injuries resulting from rear-end vehicle collisions. Turk. Neurosurg., 24(4), pp. 466-470
  25. ↑ 25.0 25.1 Ferrari R. et al. (2005). A re-examination of the whiplash associated disorders (WAD) as a systemic illness. Ann Rheum Dis., 64, pp. 1337-1342
  26. ↑ 26.0 26.1 26.2 26.3 26.4 Delfini R. et al. (1999). Delayed post-traumatic cervical instability. Surg Neurol.,51 Pp.588-595.
  27. ↑ 27.0 27.1 27.2 Sterling M. (2004). A proposed new classification system for whiplash associated disorders-implications for assessment and management. Man Ther., 9(2), pp. 60-70.
  28. ↑ 28.0 28.1 28.2 Sterling M. et al. (2006). Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain, 122, pp.102-108
  29. ↑ 29.0 29.1 Suissa et al. (2001). The relation between initial symptoms and signs and the prognosis of whiplash. Eur Spine J. 10, pp. 44-49. 
  30. ↑ 30.0 30.1 30.2 30.3 30.4 30.5 30.6 Sturzenegger M. et al. (1994). Presenting symptoms and signs after whiplash injury: The influence of accident mechanisms. Neurol., 44, pp. 688–693 
  31. ↑ 31.0 31.1 31.2 31.3 Van Goethem J. et al. Spinal Imaging: Diagnostic Imaging of the Spine and Spinal Cord. p 258 
  32. ↑ Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502.
  33. ↑ Beeckmans K, Crunelle C, Van Ingelgom S, Michiels K, Dierckx E, Vancoillie P et al. Persistent cognitive deficits after whiplash injury: a comparative study with mild traumatic brain injury patients and healthy volunteers. Acta Neurol Belg. 2017;117(2):493-500.
  34. ↑ 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
  35. ↑ 35.0 35.1 Phillips LA. Et al. (2010). Whiplash-associated disorders: who gets depressed? Who stays depressed?. Eur. Spine J., 19(6), pp. 945-956 
  36. ↑ BINDER A., The diagnosis and treatment of nonspecific neck pain and whiplash, Eura Medicophys 2007, vol. 43, nr. 1, p. 79-89. 
  37. ↑ 37.0 37.1 37.2 Fernandez Perez AM. et al. (2012). Muscle trigger points, pressure pain threshold, and cervical range of motion in patients with high level of disability related to acute whiplash injury, J. Orthop. Sports Phys. Ther.,42(7), pp. 634-641
  38. ↑ Gargan MF. Et al. (1994).The rate of recovery following whiplash injury. Eur Spine J, 3, pp. 162
  39. ↑ 39.0 39.1 39.2 Bekkering GE. et al., KNGF-richtlijn: whiplash. Nederlands tijdschrift voor fysiotherapie nummer 3/jaargang 11
  40. ↑ Crutebo S. et al. (2010). The course of symptoms for whiplash-associated disorders in Sweden: 6-month followup study. J. Rheumatol., 37(7), pp. 1527-33
  41. ↑ 41.0 41.1 Rodriquez A. et al. (2004). Whiplash: pathophysiology, diagnosis, treatment, and prognosis. Muscle Nerve, 29, pp. 768-81. 
  42. ↑ Vernon H. The neck disability index: patient assessment and outcome monitoring in whiplash. Journal of Muskuloskeletal Pain 1996 vol. 4(4): 95-104
  43. ↑ 43.0 43.1 43.2 43.3 43.4 43.5 43.6 43.7 Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders: Clinical resource guide, TRACsa: Trauma and Injury Recovery, South Australia, Adelaide 2008, p. 46-69.
  44. ↑ STENNEBERG MS. et al. « Validation of a new questionnaire to assess the impact of Whiplash Associated Disorders: The Whiplash Activity and participation List (WAL) » Man Ther. vol. 20, nr. 1, p. 84-89, 2015.
  45. ↑ SEE KS. “ Identifying upper limb disability in patients with persistent whiplash. “ Man Ther, vol. 20, nr. 3, p. 487-493, 2015.
  46. ↑ ANGST F. et al. (2014). Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective, outcome study. BMC Musculoskelet Disord., 15, 130.
  47. ↑ 47.0 47.1 47.2 47.3 Sterling M. (2014). Physiotherapy management of whiplash-associated disorders (WAD). Journal of Physiotherapy, 60, pp. 5–12 Available from: https://www.sciencedirect.com/science/article/pii/S1836955314000058 (last accessed 2.2.2020)
  48. ↑ 48.0 48.1 48.2 48.3 48.4 48.5 48.6 Meeus M. et al. Pain Physician. The efficacy of patient education in whiplash associated disorders: a systematic review. 2012 Sep-Oct;15(5):351-61.
  49. ↑ 49.0 49.1 Lamb SE. Et al. MINT Study Team. Managing Injuries of the Neck Trial (MINT): design of a randomised controlled trial of treatments for whiplash associated disorders. BMC Musculoskelet Disord. 2007 Jan 26;8:7
  50. ↑ 50.0 50.1 50.2 50.3 Seferiadis A. et al. (2004). A review of treatment interventions in whiplash-associated disorders, Eur Spine J, 13 : 387–397 
  51. ↑ Gross A. et al. Patient education for neck pain. COCHRANE DATABASE OF SYSTEMATIC REVIEWS. 2012;3
  52. ↑ 52.0 52.1 52.2 52.3 Teasell RW. Et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2 – interventions for acute WAD. Pain Res Manage 2010;15(5):295-304
  53. ↑ Christensen SW, Rasmussen MB, Jespersen CL, Sterling M, Skou ST. Soft-collar use in rehabilitation of whiplash-associated disorders-A systematic review and meta-analysis. Musculoskeletal Science and Practice. 2021 Oct 1;55:102426.
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  55. ↑ Söderlund A. et al. (2000). Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clin Rehabil. 4(5):457-67.
  56. ↑ Bonk AD. Et al. (2000). Prospective, randomised, controlled study of activity versus collar, and the natural history for whiplash injury, in Germany. World Congress on Whiplash-Associated Disorders in Vancouver, British Columbia, Canada, February 1999. J Musculoskel Pain 8: 123–132
  57. ↑ Conlin A. et al. (2005). Treatment of whiplash-associated disorders-part I: Non-invasive interventions. Pain Res Manag 10(1):21-32.
  58. ↑ McKinney LA. (1989). Early mobilisation and outcome in acute sprains of the neck. BMJ 299:1006–1008,
  59. ↑ Rosenfeld M. et al.(2003). Active intervention in patients with whiplash-associated disorders improves long-term prognosis. A randomised controlled trial. Spine 28:2491–2498 
  60. ↑ Vendrig A. et al. (2000). Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck. Spine, 25 (2): p.238–244 (4)
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  62. ↑ Aarnio M, Fredrikson M, Lampa E, Sörensen J, Gordh T, Linnman C. Whiplash injuries associated with experienced pain and disability can be visualized with [11C]-D-deprenyl positron emission tomography and computed tomography. Pain. 2022 Mar;163(3):489.
  63. ↑ Landén Ludvigsson, M., Peterson, G. and Peolsson, A., 2019. The effect of three exercise approaches on health-related quality of life, and factors associated with its improvement in chronic whiplash-associated disorders: analysis of a randomized controlled trial. Quality of Life Research, 28(2), pp.357-368.
  64. ↑ Hansen IR. et al. Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: design of a randomised controlled trial. BMC musculoskelet disord. 2011; 12 
  65. ↑ TEASELL RW. Et al., A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD, Pain Res Manag 2010, vol. 15, nr. 5, p. 313-322.
  66. ↑ Björsenius V, Löfgren M, Stålnacke BM. One-Year Follow-Up after Multimodal Rehabilitation for Patients with Whiplash-Associated Disorders. International Journal of Environmental Research and Public Health. 2020 Jul;17(13):4784.
  67. ↑ SÖDERLUND A. and LINDBERG P., An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic whiplash associated disorders, WAD, Disabil Rehabil 2001, vol. 23, nr. 10, p. 436-447. 
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