Whiplash-Associated Disorders

What is Whiplash Associated Disorder (WAD)?

Whiplash-associated disorder (WAD) is the term that describes the consequences of a whiplash injury. Whiplash is defined as an acceleration-deceleration mechanism of energy transfer to the neck. This mechanism typically occurs during a motor vehicle collision, especially rear-end or side-impact collisions, but can also result from diving or other mishaps. The impact may lead to bony or soft-tissue injuries (whiplash-injury), which in turn can cause a variety of clinical manifestations. WAD is the term given for the collection of symptoms affecting the neck that are triggered by an accident with this acceleration–deceleration mechanism. The cardinal symptom is neck pain, but neck stiffness, dizziness, headaches, fatigue, upper limb paraesthesia (numbness/tingling), concentration difficulties, psychological factors, and emotional sequelae are also commonly reported symptoms associated with chronic WAD. Neck-related pain in WAD is associated with disability, decreased quality of life, and psychological distress.

Grades of WADThe classification system of WAD represents the severity of clinical symptoms. Based on these symptoms, there are five categories (0-IV). Most patients are classified in WAD I and WAD II classifications. The classification grades are:

• Grade 0: No complaint about neck pain and no physical signs.
• Grade I: Neck complaint of pain, stiffness, or tenderness only and no physical signs.
• Grade II: Neck complaint and musculoskeletal signs. Musculoskeletal signs include decreased range of movement and point tenderness.
• Grade III: Neck complaint and neurological signs. Neurological signs include decreased or absent deep tendon reflexes, muscle weakness, and sensory deficits. Grade III could also have musculoskeletal signs.
• Grade IV: Neck complaint and fracture or dislocation.

Anatomy of Whiplash Injury

• Muscles
  • Whiplash injury can lead to muscle strain.
  • Muscle tenderness is considered a musculoskeletal sign in WAD Grade II.
  • Muscle weakness is a neurological sign in WAD Grade III.
  • Study findings demonstrate movement, muscle, and motor control changes in the neck and shoulder girdles of patients with neck pain, including WAD. These include inferior performance in tests of motor control involving the cervical flexor, extensor, and scapular muscle groups, changes in muscle morphology of the cervical flexor and extensor muscles, and loss of strength and endurance of cervical and scapular muscle groups. Deep muscles' stability is also part of the physical examination.
  • Trigger points, which are discrete areas of tenderness often associated with palpable differences in muscle compliance, are a common feature in WAD.
• Ligaments
  • Whiplash injury can cause ligament sprains.
  • Injury to ligaments is considered likely to be present to varying degrees in some patients.
• Joints
  • Injury to zygapophyseal joints (facet joints) has been detected via radiofrequency neurotomy techniques in highly selected patients with chronic WAD.
  • Decreased range of movement of the neck is a musculoskeletal sign in WAD Grade II.
  • Sensorimotor changes in WAD can include increased joint re-positioning errors and poor kinaesthetic awareness.
• Nerves
  • Whiplash injury can lead to nerve irritation.
  • Neurological signs, including decreased or absent deep tendon reflexes, muscle weakness, and sensory deficits, are present in WAD Grade III.
  • Upper limb paraesthesia or anaesthesia is a commonly reported symptom associated with WAD.
  • Sensorimotor changes in WAD can affect head and eye movement control.
• Bones
  • Bony injuries can result from the whiplash mechanism.
  • A neck complaint accompanied by a fracture or dislocation is classified as WAD Grade IV.

Causes and Risk Factors

Causes of Whiplash Injury

Whiplash injury is primarily defined as an acceleration-deceleration mechanism of energy transfer to the neck. This mechanism can result in bony and soft tissue injuries, which then lead to a variety of clinical symptoms collectively called Whiplash-Associated Disorders (WAD).

The most common cause for this mechanism is a motor vehicle collision, particularly rear-end or side-impact collisions. Whiplash injuries are reported to be the most common injury following a motor vehicle collision. .

Delayed Whiplash Symptoms

Symptoms associated with whiplash injury typically develop rapidly after the causative event. However, they are also recognised to sometimes appear hours or even days after the event.

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Physiotherapy Management for WAD

Management of WAD varies based on the severity of symptoms. Physiotherapy is a common treatment for whiplash injury.

1. Early Stage (Acute: usually defined as 0–12 weeks)

In the early acute stages, the mainstay of management is the provision of advice encouraging return to usual activity and exercise.

• Pain Control: While medication is usually needed in the acute phase, including NSAIDs and muscle relaxants, physiotherapy techniques for pain relief mentioned in the sources include heat application, lymphatic drainage, massage, soft-tissue treatment, trigger point treatment, and electrotherapy. Advice about medication and symptomatic control is also part of management.
• Movement: It is strongly recommended to avoid prolonged immobilization with a soft collar, as evidence suggests it is ineffective and may impede recovery. Early implementation of active exercise has a positive effect on pain and disability. Patients who "act as usual" post-whiplash injury have significantly better outcomes. Reassure patients that maintaining movement is harmless and will aid in long-term improvement. Exercise programs, active mobilization, and advice to act as usual appeared to improve recovery in acute WAD. Simple mobilization exercises and advice to remain active may produce better long-term results than more formal physiotherapy exercise programs, although both are superior to no treatment. Various types of exercises have been investigated, including range-of-movement exercises, McKenzie exercises, postural exercises, strengthening, and motor control exercises. Physiotherapy protocols can include cervical, thoracic, and shoulder region exercises aimed at restoring movement, as well as specific exercises for postural muscle control and proprioception. Exercises are prescribed and progressed based on the individual's risk profile.
• Posture Education: Advice about posture and positioning can be part of physiotherapy management.
• General Advice/Education: Education and advice to return to activity and exercise are the cornerstones of early treatment. This can include advice about symptom management, reassurance, and relaxation. Educating the patient about the mechanism of injury, structures affected, and providing a realistic overview of treatment options and prognosis is recommended.

2. Subacute (usually defined as two to 12 weeks or 3 to 6 months)

• Manual Therapy: Manual therapies, including joint mobilization, can be part of a multimodal approach. Physiotherapy protocols may include cervical spine mobilisations (Maitland technique, grades I to IV), thoracic spine mobilisations (Maitland technique, grades I to IV), thoracic spine manipulation (Maitland technique, grade V), and shoulder-complex mobilisations.
• Strengthening: While not strictly limited to the subacute phase, strengthening exercises are mentioned as part of various exercise programs for WAD. Specific exercises like neck stabilization exercise showed significant short-term effects. Deep muscles' stability is part of the physical examination, implying exercises to improve this may be used. Muscle control exercises of the cervical, thoracic, and shoulder region are mentioned within an interdisciplinary approach.
• Nerve Mobility: The sources do not explicitly mention "neural glides." However, they note that whiplash can lead to nerve irritation [Previous conversation], neurological signs are part of WAD Grade III, and widespread pain or non-localised hypersensitivity can occur. Pain neurophysiology education has shown promise in improving cognitions, pain thresholds, and movement performance in chronic whiplash, suggesting that addressing altered pain processing, potentially involving nerve sensitivity, is relevant.

3. Chronic (usually defined as longer than 12 weeks or over 6 months)

• Exercise Programs: Exercise programs appear to be the most effective noninvasive intervention for chronic WAD and are effective in relieving pain. Various types of exercise regimens have been investigated, including graded functional exercise, specific motor and sensorimotor retraining, muscle strength and endurance training, vestibular exercises, and exercises challenging the postural system, with similar reported effects regardless of the exercise type.
• Combination of Exercise & Advice: The combination of Exercise & Advice is considered the most suitable intervention for the physiotherapy management of chronic WAD, with long-term effectiveness demonstrated using various outcome measures. Specific programs have included aerobic, strengthening, and endurance exercises combined with a behavioral approach, or specific cervical spine exercises, postural re-education, sensorimotor exercises, and muscle training with a behavioral approach. Neck-specific exercises and education have also shown effectiveness.
• Functional Rehab: Functional exercises are intended to facilitate return to activities and work. Multimodal therapy can include functional activities and posture control. Interdisciplinary programs for chronic pain and WAD have included graded exercise and cognitive behavioural therapy aimed at promoting return to work and reorienting patients towards realistic goals. This implies a focus on functional recovery.
• Other Techniques for Chronic WAD: Other noninvasive therapies explored for chronic WAD include manual joint manipulation and myofeedback training, but the evidence is insufficient to determine their effectiveness with confidence. Multimodal treatment (education, exercise, manual therapy) is likely effective for chronic WAD. General pain management guidelines are recommended for medication in chronic WAD.

In summary, for acute WAD, the emphasis is on avoiding immobilization and encouraging early activity and movement, supported by advice and education, and potentially pain relief techniques like manual therapy or modalities. For subacute WAD, there's mention of multimodal therapy, including manual techniques and exercise, although one source suggests interventions in this phase might not be effective. For chronic WAD, exercise programs, particularly when combined with advice and education, are highlighted as the most suitable intervention for long-term effectiveness in pain relief and improving function. While specific "best exercises" are not definitively identified, exercise and remaining active are consistently recommended over rest or immobilization across stages.

Prognosis and Recovery Timeline

The duration of symptoms categorizes WAD into three phases: acute (less than three months or less than 12 weeks), subacute (three to six months or two to 12 weeks), and chronic (over six months or longer than 12 weeks).

General Prognosis and Recovery Timeline

Although it is often believed that most whiplash patients recover naturally within a few months, recent research suggests that recovery can be prolonged. Most individuals who recover from acute whiplash injury do so within the first three months after the injury, with recovery often occurring during the first 2-3 months. However, a substantial number of people will develop chronic symptoms. Approximately 50% of patients still report neck pain one year after injury, and 40-60% have chronic symptoms. Chronic Whiplash Syndrome is defined as a condition lasting over six months.

Several factors are associated with delayed or poor recovery, including higher initial pain levels (specifically noted as >5.5/10 on a VAS scale), decreased cervical spine mobility immediately after injury, pre-existing neck trauma, older age, and female gender. Psychosocial factors like fear avoidance, catastrophizing, anxiety, and depression also influence the recovery process. Higher initial Neck Disability Index (NDI) scores (≥40%) are also predictive of moderate/severe disability at 12 months.

Physiotherapy Management by Stage

• Acute Stage (0-12 weeks) - Often includes WAD Grade I and II:
  • In the early acute stages, the main recommendation is to encourage a return to usual activity and exercise. Patients who "act as usual" post-injury tend to have significantly better outcomes. It is important to avoid prolonged immobilization with a soft collar, as it is considered ineffective and may hinder recovery.
  • Early implementation of active exercise has a positive effect on pain and disability. Simple mobilization exercises and advice to remain active may lead to better long-term results than more formal exercise programs, although both are superior to no treatment. Physiotherapy protocols can include range-of-movement exercises, as well as specific exercises for postural muscle control and proprioception.
  • Pain control techniques mentioned include heat application, lymphatic drainage, massage, soft-tissue treatment, trigger point treatment, and electrotherapy, alongside advice about medication. However, medication trials in acute WAD have shown mixed results, and general pain management guidelines are often followed.
  • Education and advice to return to activity and exercise are fundamental in early treatment.
  • While the sources define acute as up to 12 weeks, a timeline of 2-6 weeks falls within this phase. Management in this period aligns with the principles of early activation and advice.
• Subacute Stage (2-12 weeks or 3-6 months) - Often includes WAD Grade II and III:
  • One source suggests that interventions initiated during the subacute phase do not appear to be effective in reducing symptoms. However, another source suggests that multimodal therapy, combining education, exercise, and manual therapy, has strong evidence supporting its use between 2 and 12 weeks following injury.
  • Multimodal therapy can include manual therapies (such as joint mobilization), relaxation techniques, ongoing education, and exercises provided as a package of care. Some studies reported favorable outcomes for manual therapy, although they were methodologically weak with short-term follow-up. Low velocity mobilization techniques can be part of a multimodal approach. Muscle control exercises of the cervical, thoracic, and shoulder region are also mentioned within an interdisciplinary approach.
  • A timeframe of 6-12 weeks falls within the subacute phase as defined by the sources. Management may involve manual therapy and exercise as part of a multimodal approach, though the evidence on effectiveness specifically initiated during this phase is conflicting. WAD Grade III involves neurological signs and may necessitate referral to a specialist, implying a need for more complex or multidisciplinary care, which aligns with your query point.
• Chronic Cases (Over 12 weeks or Over 6 months):
  • Chronic WAD is defined by symptoms lasting longer than 12 weeks or over 6 months. A substantial proportion of individuals develop chronic symptoms.
  • For chronic WAD, exercise programs are highlighted as the most effective noninvasive intervention for relieving pain, at least in the short term. However, these benefits may not be maintained over the long term.
  • The combination of Exercise & Advice is considered the most suitable intervention for the physiotherapy management of chronic WAD, showing long-term effectiveness. This has included various exercise regimens like graded functional exercise, specific motor and sensorimotor retraining, muscle strength and endurance training, vestibular exercises, and exercises challenging the postural system. Neck-specific exercises and education have also shown effectiveness.
  • Multimodal treatment (combining education, exercise, and manual therapy) is also likely effective for chronic WAD.
  • Interdisciplinary programs, which may include graded exercise and cognitive behavioural therapy, are also used, sometimes aimed at promoting return to work and realistic goal-setting. Pain neurophysiology education has also shown promise in improving outcomes in chronic whiplash.
  • The sources do not explicitly mention "vestibular therapy" as a specific, standalone treatment recommendation for dizziness in chronic WAD, although dizziness is a known symptom, and exercises challenging the postural system are part of recommended exercise types for chronic WAD.

Preventing Long-Term Complications

Here's what the sources suggest for preventing long-term complications:

Do’s:

• Start gentle movement ASAP (avoid "brace mentality"): The sources strongly recommend early implementation of active exercise and activation-based therapies for acute WAD. Starting therapy as soon as possible after sustaining the injury seems to be very important, as a longer delay may increase the risk of chronic symptoms. Encouraging a return to usual activity and exercise is considered the mainstay of management for acute WAD and a cornerstone of early treatment. Patients who "act as usual" post-injury tend to have significantly better outcomes. Advice to remain active within tolerable levels is effective in reducing pain and improving function, especially in the early stages. Reassuring the patient that continuing to maintain movement is harmless and will aid long-term improvement is important. Simple mobilization exercises and advice to remain active may lead to better long-term results than more formal exercise programs, although the latter are still superior to no treatment.
• Strengthen neck/shoulders progressively: While the sources note it's not entirely clear which type of exercise is most effective or if specific exercise is better than general activity or advice in the acute phase, strengthening exercises are mentioned as part of exercise programs investigated for WAD. For chronic WAD, muscle strength and endurance training has been investigated. Within some physiotherapy approaches described, recommendations include providing stabilization exercises targeting deep neck flexors and scapula stabilizers, and general exercises for the cervical, thoracic, and shoulder regions aimed at restoring movement. A graded approach to exercises is encouraged to avoid flare-ups.
• WAD exercises at home: The sources indicate that home exercise or home training can be part of the management for WAD, for both acute and chronic stages. Examples of exercises or types of exercises mentioned that can be done at home include:
  • Active resistance exercises daily at home.
  • Home neck exercises performed within the limit of pain.
  • A self-mobilization exercise program detailed on an advice sheet, to be initiated immediately.
  • Physical activity and psychological skills at home as part of an interdisciplinary approach.
  • General mobility exercises for the cervical and thoracic spine.
  • Stabilization exercises targeting deep neck flexors and scapula stabilizers.
  • Slow eye-head-neck coordination exercises (as part of a 4-week home exercise program).
  • Isometric and isotonic exercises (in the context of advice for home training).
  • Advice regarding relaxation techniques, posture, and home exercise.
  • Exercises for the cervical, thoracic, and shoulder regions, as well as postural muscle control (upper cervical flexion, scapular setting) and simple proprioception-enhancing exercises, often provided with exercise sheets for home use.

Don’ts:

• Prolonged rest or over-reliance on collars: The sources provide strong evidence that immobilization (collars, rest) is ineffective for the management of acute WAD. Immobilization with a soft collar may impede recovery by promoting prolonged neck stiffness, inhibiting movement, and discouraging patients from taking an active role in their own recovery. Activity and exercise are superior to restricting movement with a soft collar. Avoidance of movement due to fear of pain could also result in prolonging symptoms and delaying recovery. Additionally, interventions initiated during the subacute phase (two to 12 weeks or 3-6 months, depending on the source's definition) may not be effective in reducing symptoms.

In summary, the key to preventing long-term whiplash symptoms, according to the sources, is to remain active, start gentle movement and exercise early, avoid prolonged rest and soft collar use, and incorporate specific exercises aimed at mobility, stabilization, and sensorimotor control, potentially as part of a home exercise program. Education and addressing psychological factors are also important aspects of care.

FAQs About Whiplash

• "Is it safe to move my neck?"
  • Yes, it is safe to move your neck after a whiplash injury. There is strong evidence that immobilization (collars, rest) is ineffective for the management of acute WAD.
  • Prolonged use a soft collar may impede natural recovery by promoting neck stiffness, inhibiting movement, and discouraging patients from taking an active role in their own recovery. Activity and exercise are described as superior to restricting movement with a soft collar. Avoidance of movement due to fear of pain could result in prolonging the symptoms and delaying recovery.
  • Starting gentle movement as soon as possible is recommended. Activation-based therapy is recommended for the treatment of acute WAD.
  • Encouraging a return to usual activity and exercise is considered the mainstay of management for acute WAD.
  • Simple mobilization exercises and advice to remain active may lead to better long-term results than more formal exercise programs, although these are still superior to no treatment.
• "Can WAD cause dizziness?"
  • Yes, dizziness is a common symptom associated with Whiplash-Associated Disorders.
  • Other related symptoms commonly reported include neck stiffness, headaches, and unsteadiness. Visual disturbances and unsteadiness are also mentioned in the context of chronic symptoms after whiplash trauma.
  • One source references a study specifically investigating dizziness among patients with whiplash-associated disorder. Another references research on dizziness and unsteadiness following whiplash injury and their relationship with cervical joint position error, suggesting a potential link to dysfunction in the neck joints and nerves that contribute to balance and spatial orientation.
• "can whiplash cause headaches?"
  • Yes, headache is listed as a commonly reported symptom following acceleration/deceleration injury to the neck. It is considered one of the main symptoms of chronic WAD. Headache intensity has been assessed in studies related to chronic WAD.

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