WHIPLASH ASSOCIATED DISORDER: Causes and Treatment

Whiplash can be defined as “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 diving or other mishaps. 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). 

What is the classification of WAD?

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

• Grade 0: No complaints about the neck. No physical sign(s).
• Grade I: Neck complaint of pain, stiffness or tenderness only. No physical sign(s).
• Grade II: Neck complaint AND musculoskeletal sign(s). Musculoskeletal signs include decreased range of motion and point tenderness.
• Grade III: Neck complaint AND neurological sign(s). Neurological signs include decreased range of motion and point tenderness.
• Grade IV: Neck complaint AND fracture or dislocation. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753964/) 

The incidence of whiplash injury has been increasing during the past decade ranging from 16 to 200 per 100,000 varying by geographical location. 

What are the symptoms of whiplash? 

• Grade 0: patient does not present with any physical sigs or symptoms of injury. Neck movements are normal and there is no report of associated pain after injury.
• Grade 1: Patient presents with pain and stiffness during neck movements. There may be tenderness and around the cervical spine on palpation.
• Grade 2: Patient presents with neck pain that may radiate in head, scapula, shoulder, upper back or entire upper extremity. Neck movements are painful and stiff due to muscle spasm. Physical signs of injury like bruising, swelling and tenderness maybe present. 
• Grade 3: Involves neurological symptoms because swelling and inflammation around the cervical spine may cause compression around the spinal cord and brachial plexus. The presenting symptoms may include muscle weakness, numbness, burning, tingling sensation around the neck, shoulder and arm, headaches, tinnitus, dizziness, vision and speech changes. Patient may also complain of dizziness and vertigo. 
• Grade 4: may include all of grade 3 symptoms but at a more intense level along with instability of the cervical spine. This may indicate ligament rupture, vertebral fracture resulting in loss of vertebral alignment and cord compression. 

What is the Patho anatomy of whiplash injury?

Clinical evidence shows different tissues and joints that may be injured during the impact.

• Anterior longitudinal ligament
• Intervertebral disk
• Dorsal root ganglion
• Vertebral artery
• Muscles – mainly sternocleidomastoid, semispinalis capitis (https://www.physio-pedia.com/The_Biomechanics_Behind_Whiplash_Associated_Disorder#:~:text=dislocation%20or%20fracture.-,Pathophysiology,a%20loss%20of%20cervical%20lordosis.) 

What are the causes of WAD?

Whiplash happens when your movement speed or direction of travel suddenly changes. Some of the most common activities that can lead to whiplash include: 

• Motor vehicle crashes (most common)
• Contact sports (football, hockey, rugby)
• Roller coasters 
• Rarely, slips, trips and fall may also cause WAD if the neck is in a vulnerable angle (https://my.clevelandclinic.org/health/diseases/11982-whiplash) 

How is Whiplash diagnosed? 

Physical examination will include postural and movement assessment on observation along with other symptoms like swelling, bruising and spinal deviation. It will also include palpatory examination of the cervical spine to assess the pain intensity, location and tissue irritability.

Complete neuro-musculoskeletal examination will include:

• Degree of movement where the pain is most intense
• Extent of swelling and bruising 
• Special tests of neck and adjacent joints
• Neurodynamic assessment
• Sensorimotor and reflex testing of upper and lower limbs 

Range of movement exam of neck, upper back, shoulder

Imaging 

• X-rays can reveal fractures or malalignment in cervical spine.
• CT scan can show further details for bony damage.
• MRI scans can show some soft tissue injuries, such as damage to spinal cord, disks or ligaments. 

What is the treatment for WAD?

Pain management

• Rest for a day or two just after the injury will help. It may take up to a day for all the symptoms to appear. 
• Hot and cold packs for 15 minutes a day will help reduce inflammation and improve blood flow around injured area.
• Pain relievers such as acetaminophen (Tylenol) and ibuprofen (Advil) often can control mild to moderate whiplash pain. 
• Prescription medication such as anti-depressant drugs maybe given to patients suffering to more intense nerve pain.
• Short-term use of muscle relaxants may help combat muscle pain and spasm and improve sleep.
•  Lidocaine injection into painful muscle area might decrease pain to be able to pursue physiotherapy. 

Physical therapy 

• Stabilisation exercises for deep neck flexors and scapula will help improve spinal stability for neck and shoulder movements. 
• Transcutaneous electrical nerve stimulation will help reduce pain.

Advise patient to continue with their activities of daily living within tolerable levels to promote early return to function. (https://www.mayoclinic.org/diseases-conditions/whiplash/diagnosis-treatment/drc-20378926)

Active mobility exercises of neck, upper back and shoulders will help recovery by improving range of movements and reduce stiffness.

Radiofrequency nerve ablation 

• Nerves sending pain signal to the brain are blocked with radiofrequency energy. 

Spine surgery is indicated if the patient has fractured vertebra or severe spinal stability that can lead to cord compression. 

How long does whiplash last?

Most people with lower grades of whiplash recover within few days or weeks. Whiplash lasts longer when complications lead to chronic pain or inflammation in and around the spine. The timeline for recovery from chronic complications of whiplash can vary widely, so a healthcare provider is the best source of information on what to expect from each specific case. 

How can I reduce the risk and prevent complications from whiplash? 

• Putting driving seat in right position with good head rest
• Wearing the seat-belt which should be snug fitting across the body
• Driving safely and cautiously to avoid sudden use of brakes 
• Play contact sport safely using proper protective gear
• Use proper safety direction before getting on a roller coaster (https://my.clevelandclinic.org/health/diseases/11982-whiplash)