All about Whiplash Injuries - part 2
If you have not read part 1, which I posted last week, I'd recommend having a quick read.
In Part 2 of this article, I will discuss the assessment of a patient with a suspected whiplash-associated disorder (WAD), as well as an evidence and experience-based physiotherapy treatment approach.
When examining a patient who has been involved in a road traffic or motor vehicle accident, we assess for:
- Impairments in motor and sensory function
- Difficulty with joint repositioning
- Balance loss
- Reduced neck movements with faulty movement patterns
- Joint and muscle tenderness.
Although not prognostic, positive findings can help with diagnosis and early treatment for whiplash.
Associated symptoms often include:
- A heightened response to painful stimuli (allodynia)
- A high level of easily provoked pain
- Excessive sensitivity to cold as well as disturbed sleep
The Quebec Task Force classification of WAD can also be used and may be necessary for medico-legal purposes. This classification system is based mainly on neck pain symptom severity, the extent of loss of movement, level of tenderness about the neck region, and whether or not there are neurological signs or fracture.
X-rays or scans are not always necessary to make a WAD diagnosis; however, they may be used to exclude a fracture in more severe cases.
The extent of any associate psychological factors may impact on recovery times and overall prognosis. As such, psychological factors must be identified early, and appropriate and timely treatment provided. Common associated psychological factors include:
- Initial moderate post-traumatic stress syndrome (PTSS)
- Pain catastrophising
- Symptoms of depressed mood or depression
- Lower expectations of recovery
Early symptoms of PTSS may include:
- Sleep disturbance with thoughts of the accident
- Avoidance of driving due to fear
Depending on the severity and extent of our assessment findings, a diagnosis of WAD may be applicable, in which case specific evidence-based physiotherapy treatment should be provided.
A multi-modal evidence-based physiotherapy treatment programme may include:
Advice and education
-Advice should to try and return to usual activity and exercise as soon as possible.
-Unfortunately, despite advice to keep moving and exercising, a significant number of WAD sufferers will develop chronic pain and disability, as such other forms of treatment should also be offered.
-There is strong evidence that immobilisation (neck collars/ complete rest) is ineffective for acute WAD.
-Education and advice booklets, videos, websites etc. which help patients better understand the condition.
-Education regarding pain neurophysiology (as used when treating other chronic pain conditions).
-Physical rehabilitation exercises may be useful in the earlier stages of whiplash but show only small effect sizes in chronic whiplash.
-For long term general health, the patient needs to be advised to undertake regular activity and exercise.
-Spinal manual therapy is used in the clinical management of cervical pain associated with WAD, usually in association with exercises and advice.
-Manual therapy is a hands-on treatment and there is no evidence to suggest it creates patient dependency.
- There is research evidence to support the analgesic (pain-relieving effects) of manual therapy by Gross et al. 2015, Wong et al. 2016, Sutton et al. 2016 and Leininger et al. 2016.
- Manual therapy has also been shown to be more cost-effective compared to exercise alone (Leininger et al. 2016, Tsertsvadze et al. 2014, Michaleff et al. 2012).
-Pain medication may be prescribed in the early stages to reduce initial pain symptoms associated with WAD.
-Medication, as well as cognitive behavioural therapy to assist with the psychological aspects of pain, may be indicated. However, the burden of requiring visits with several practitioners may also lead to poor compliance.
-It is now aknowledged that physiotherapists with appropriate training are well placed to provide this type of intervention.
Which techniques to use and at what stage of the treatment programme is determined by the experience of the treating physiotherapist, usually in collaboration with the patient. Health outcomes, subject and objective measures should be monitored, and treatment continued only when there is a definite improvement over a realistic period.
If recovery occurs, the majority will occur within the first 2-3 months post-injury and then tends to plateau, with slower recovery up to one year or longer in some cases. Unfortunately, some will go on to develop chronic pain from which full recovery may not occur.
For the best chance of recovery, early assessment and intervention are recommended. If you have been in an accident, and suspect you may be suffering from a whiplash injury, I would recommend you consult with your GP and request a physiotherapy referral as soon as possible.
In good health,
Lorraine Carroll MSc Phyty, BSc Physio, CMA, MISCP
Chartered Musculoskeletal Physiotherapist