Driving Force

Whiplash disorder is more than a simple pain in the neck.

Like back pain, whiplash injuries have long been associated with malingerers, symptom magnification and the stigma of unfounded lawsuits.

But for those who truly sustain a whiplash-associated injury, the pain for people is real, intense and debilitating.

In severe cases, back and neck pain can be just the start, as the injury manifests into non-spinal symptoms—severe headaches, paresthesia, tinnitus, dizziness and concentration problems. Many researchers view whiplash as a systemic illness rather than an acute injury.

The overwhelming majority of whiplash cases arise from automobile accidents. Occasionally, sports injuries and other accidents can also force the neck beyond its normal range of motion, which results in hyperextension and flexion of the cervical spine.

Regardless of the precipitating event, whiplash still elicits clinical controversy. Some clinicians feel its etiology arises from facet joint damage, while others implicate intervertebral disks, ligaments or muscular pathology. Treatments are just as hotly debated—some clinicians recommend rest, while others advocate exercise. Still others swear by manipulation or steroid injections.

Because of these uncertainties and its frequency in rehabilitation clinics, it’s pertinent to take a closer look at whiplash and evidence-based treatments that can bring relief.

Identifying the Disorder

In 1995, an international coalition of experts known as the Quebec Task Force released a consensus definition of whiplash disorder and its effects, which changed the way providers and insurance companies view these cases.

They defined whiplash as an acceleration-deceleration mechanism of energy transfer to the neck.1 The impact can result in bony or soft-tissue injuries (whiplash injuries), which may lead to a variety of clinical manifestations, known as whiplash-associated disorders.

Whiplash has been used interchangeably with the clinical terms flexion-extension neck injury and soft tissue cervical hyperextension injury. While current research implicates the zygapophysial joint as the main pain generator in chronic whiplash pain, the etiology of the disorder remains under debate.2

The Quebec Task Force devised a five-tier grading system of symptom severity, which helped set guidelines for treatment. Grade 0 injuries show no physical signs, and the patient has no pain complaints. Grade 1 injuries show no physical signs, but the patient complains of stiffness or tenderness around the neck. Grade 2 injuries result in neck pain complaints and musculoskeletal signs (decreased range of motion or point tenderness).

Grade 3 injuries result in neck pain complaints and neurological signs (decreased deep tendon reflexes, weakness or sensory deficits.) Grade 4 injuries, the most severe, are associated with a fracture or dislocation. The majority of injuries fall into grades 1 and 2.

A wide-scale study in Canada led authors to propose that symptoms of whiplash form a “general illness” that can be modulated by pathology, psychological responses and social context.3 Authors found that females reported more severe neck pain and headaches, and experienced more systemic symptoms than male counterparts with whiplash. Of the 4,500 women studied, a large component reported non-spinal symptoms, such as headaches (86 percent), low back pain (65 percent), dizziness/unsteadiness (48 percent) and upper extremity numbness (46 percent).

Less common findings, though statistically significant, were nausea, lower extremity numbness, concentration problems, jaw pain and tinnitus. From these findings it’s evident that whiplash can’t be identified by a single anatomical region of injury.

Though most current research identifies the facet joint as the main pain generator, this theory hasn’t been able to clarify the systemic symptoms associated with whiplash disorder. For instance, brachial plexus stretch injuries are common. In one study, as much as 38 percent of patients sustained this finding.4 The presence of a brachial plexus stretch injury is commonly associated with a poor clinical outcome.

Also, trauma to the upper body during a whiplash injury can result in neural compressive irritation at the thoracic outlet.5 Thoracic outlet symptoms could be related to direct damage to the scalene muscles and cervical disk disease. These patients may benefit from surgery.5 Some patients even present with neck, arm and hand pain that responds to carpal tunnel decompression surgery.6

Because of its widespread symptoms, whiplash disorders exert devastating socioeconomic repercussions, due to the rising cost of diagnosing and treating these injuries, and the effect of litigation on insurance claims. The Quebec Task Force found that the median time to recovery (end of disability compensation) was 31 days.1 Fewer than 2 percent of subjects were still disabled 1 year after an initial injury.

However, the cases that linger beyond a normal recovery time frame exert the largest socioeconomic impact. Only 12 percent of patients were receiving disability 6 months after an injury, but this minority was responsible for 46 percent of total costs.1 Another 38 percent of costs went to those with disabilities lasting from 2 to 6 months after injury. And long-term degenerative changes are more prevalent in those who’ve sustained soft tissue injuries of the cervical spine.7

Promoting Early Mobility

The symptoms that can accompany whiplash encourage various treatment choices. You can elicit relief with noninvasive methods, such as range of motion exercises, postural mechanics, ultrasound, electrical stimulation, myofascial release, traction, mobilization and manipulation. More aggressive approaches include steroid injections, facet blocks, botulinum treatment, carpal tunnel decompression and cervical discectomy.

A new approach to treatment is the use of botulinum toxin, which can reduce muscle spasms. According to a 2002 article in the Clinical Journal of Pain, Type A toxin (BOTOX) has been studied in small trials of patients with whiplash associated disorders (WAD) and has been observed to relieve pain and improve range of motion. Although botulinum toxin hasn’t been evaluated in large long-term trials, initial data suggests a role for this agent to treat WAD.

The Quebec Task Force found little evidence for corticosteroid injections, pulsed electromagnetic treatment and cervical soft collars. In fact, the task force found that collars can actually prolong disability, as immobilization may increase scar tissue and reduce cervical mobility.1

You should also avoid muscle relaxants and bed rest.

Instead, current research substantiates activity-based treatments. Mobilization, manipulation and exercises, in combination with analgesics or nonsteroidal anti-inflammatory agents, are effective on a time-limited basis. Interventions focused on early return to mobility, starting at the stage of fibroplasias and throughout the maturation phase, can enhance optimal healing.1

Recent research is clarifying the initial findings of the Quebec Task Force and validating the role of early mobility to manage these injuries. One study found that supervised physical therapy equates to lower health care costs.8 An early intervention group that participated in 3 to 7 weeks of therapist-led functional exercises and multidisciplinary care saved an average of 1,000 Canadian dollars per patient, due to a higher rate of file closure and the end of compensation.

Another study compared soft collar treatment with physical therapy. The physical therapy group reported significantly less pain at 6 weeks and 6 months.9 And another study found active early mobilization superior to a standard treatment of rest, short-term immobilization in a cervical collar, and a cautious, gradual self-exercise program.10 The active treatment reduced pain, sick leave and costs after 6 and 36 months.

Researchers witnessed the value of professional supervision by comparing supervised training programs to home training regimens.11 Supervised training resulted in more rapid improvement, decreased fear of movement, and reductions in analgesic consumption and pain disability at 3 months post-injury.

Evidence indicates that whiplash leads to more than just neck pain. You must take symptoms seriously and resist the urge to automatically dismiss patients as malingerers. Examine and evaluate the cervical spine, thoracic and lumbar spine, neural tension, temporomandibular joint mechanics, vestibular function and myofascial mobility, which can contribute to systemic symptoms following a whiplash injury.

References

1.Spitzer, W.O., Skovron, M.L., Salmi, L.R. et al. (1995). Scientific monograph of the Quebec Task Force on whiplash-associated disorders. Spine, 20(suppl 8), 1-73S.

2.Barnsley, L., Lord, S.M., Wallis, B.J., & Bogduk, N. (1995). The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine, 20(1), 20-25.

3.Ferrari, R., Russell, A.S., Carroll, L.J., & Cassidy, J.D. (2005). A re-examination of the whiplash associated disorders (WAD) as a systemic illness. Annals of the Rheumatic Diseases, 64(9), 1337-1342.

4.Ide, M., Ide, J., Yamaga, M., & Takagi, K. (2001). Symptoms and signs of irritation of the brachial plexus in whiplash injuries. Journal of Bone & Joint Surgery (British Volume), 83(2), 226-229.

5.Kai, Y., Oyama, M., Kurose, S. et al. (2001). Neurogenic thoracic outlet syndrome in whiplash injury. Journal of Spinal Disorders, 14(6), 487-493.

6.Alpar, E.K., Onuoha, G., Killampalli, V.V., & Waters, R. (2002). Management of chronic pain in whiplash injury. Journal of Bone & Joint Surgery (British volume), 84(6), 807-811.

7.Watkinson, A., Gargan, M.F., & Bannister, G.C. (1991). Prognostic factors in soft tissue injuries of the cervical spine. Injury, 22(4), 307-309.

8.Suissa, S., Giroux, M., Gervais, M., et al. (2006). Assessing a whiplash management model: A population-based nonrandomized intervention study. Journal of Rheumatology, 33(3), 581-587.

9.Vassiliou, T., Kaluza, G., Putzke, C. et al. (2006). Physical therapy and active exercises: An adequate treatment for prevention of late whiplash syndrome? Randomized controlled trial in 200 patients. Pain, 124(1-2), 69-76.

10.Rosenfeld, M., Seferiadis, A., & Gunnarsson, R. (2006). Active involvement and intervention in patients exposed to whiplash trauma in automobile crashes reduces costs: A randomized, controlled clinical trial and health economic evaluation. Spine, 31(16), 1799-1804.

11.Bunketorp, L., Lindh, M., Carlsson, J., & Stener-Victorin, E. (2006). The effectiveness of a supervised physical training model tailored to the individual needs of patients with whiplash-associated disorders: A randomized controlled trial. Clinical Rehabilitation, 20(3), 201-217.

Jeremy Bruce, MPT, is a medical student at the Medical College of Georgia in Augusta, and begins his orthopedic surgery residency at the University of Tennessee-Chattanooga this summer.