16 May Whiplash
Whiplash is a relatively common injury that is often ignored or mistreated due to lack of understanding of the condition. Whiplash is usually the result of a rear impact while in a stationary position. Early range of motion and exercises lead to a more rapid recovery than prolonged immobilisation or use of a cervical collar. Failure to properly educate and treat patients with whiplash can lead to chronic psychosocial symptoms including depression and anxiety.
Whiplash is a common term for sudden hyperflexion and hyperextension due to the rapid acceleration/deceleration forces on the neck as a result of rear end or side impact motor vehicle collisions, diving accidents and/or other mishaps. 90% of patients involved in whiplash type accidents complain of neck pain. The injury mechanism of whiplash is poorly understood, so it is the subject of intense global research. Whiplash injuries can occur in collisions at speeds as low as 8 km/h. Because of this factor, it is important to remember that even if there is no damage to the vehicle in a collision that does not mean there is no damage to the occupant/s of the vehicle. These forces may result in bony or soft tissue injuries such as discs, ligaments, tendons, neck musculature, and nerve roots. The exact injury mechanism that causes whiplash injuries is unknown. A whiplash injury may be the result of impulsive stretching of the spine, mainly the anterior longitudinal ligament which is stretched or torn, as the head snaps forward and then back again. Whiplash injuries from motor vehicle accidents, although common, remain a poorly understood clinical problem. Recent Australian data indicates that up to 60% of people may still have pain 6 months after their injury.
Symptoms: The most common symptom after a whiplash injury is neck pain or stiffness. This can occur immediately after the injury or usually within 48hrs. Other symptoms may include:
• Pain in the Shoulders and Arms
• Altered sensation such as pins and needles or numbness
• Visual and auditory symptoms
• Concentration difficulties
In recent years there has been greater investigation of whiplash and its effects. Research has revealed that people with ongoing symptoms may also have changes in the muscle or motor function of their neck and shoulder girdles. They may also experience balance disturbances; decreased proprioception and increased sensitivity to a variety of stimuli including pressure, light vibration, heat and cold. These changes not only occur in the neck, but also in body areas remote to the site of pain such as the front of the shin. The changes in sensation, where the patient experiences pain to stimuli that are usually innocuous, suggests the presence of disturbances in the neurobiological processing of pain most likely occurring within the central nervous system. Not surprisingly, people with whiplash and ongoing pain may also experience psychological distress. Not all these changes occur in every person and they usually present to varying degrees.
Whiplash Associated Disorder (WAD):
Given the wide variety of symptoms associated with whiplash injuries, the Quebec Task Force on Whiplash coined the phrase ‘Whiplash-Associated Disorders’
• WAD is a term used to describe a range of symptoms resulting from whiplash. These can vary from no symptoms to severe.
• WAD injuries are usually graded on a severity scale between 0-4.
Grade 0 No pain or discomfort. No physical signs of injury.
Grade 1 Neck pain, stiffness or tenderness. No physical signs of injury.
Grade 2 Neck pain, stiffness or tenderness and some physical signs of injury such as point tenderness or trouble turning the head.
Grade 3 Pain, stiffness or tenderness and neurological signs of injury, such as changes to reflexes or weakness in the arms.
Grade 4 Pain and fracture or dislocation of the neck.
Early rehabilitation for whiplash is dependent on the grade category. It can be categorized as grade 0 being no pain to grade 4 with a cervical bone fracture or dislocation. Grade 4 obviously needs admission to hospital while grade 0-3 can be managed as outpatients. The symptoms from the potential injury to the cervical spine may be debilitating, and pain was reported to be one of the biggest stressor events experienced in daily living, so it is important to begin rehabilitation immediately to prevent future pain.
Current research supports that active mobilisation rather than a soft collar results in a more prompt recovery both in the short and long term perspective. Furthermore, Schnabel and colleagues stated that the soft collar is not a suitable medium for rehabilitation, and the best way of recovery is to include an active rehabilitation program that includes physiotherapy exercises and postural modifications. Another study found patients who participated in active therapy shortly after injury increased mobilisation of the neck with significantly less pain within four weeks when compared to patients using a cervical collar.
Early Treatment is aimed to decrease pain, reduce inflammation and regain function and may include:
• joint mobilisation
• soft tissue mobilisation & massage
• postural exercise • gentle ROM & stretching
• rest from aggravating activities
• exercise modification
• exercises to improve flexibility, strength (deep neck flexors) and posture
Education and Advice is an important part of treatment and includes:
• anti – inflammatory & pain medication advice
• ergonomic advice
• the use of an appropriate pillow for sleeping
• advice on the gradual increase in exercise & activity
Passive treatments such as dry needling and electrotherapy may sometimes be used as a complement to active exercises. Return to normal activities of daily living should be encouraged as soon as possible to maximise and expedite full recovery. After the acute stage Physio including Neural Stretches and Clinical Pilates can be helpful in returning the patient to pre injury status.
Symptoms remaining more than six months after trauma is labelled Whiplash Syndrome. The main purpose with early rehabilitation is to reduce the risk for development of Whiplash syndrome. 10% of whiplash patients will suffer long-lasting neck pain – this pain can be severe enough to inhibit enjoyment of a normal lifestyle -experts differ greatly in the way they understand this chronic whiplash syndrome and in the way they treat their patients. Some believe that nerve or joints are the cause of the chronic pain (there is evidence of persistent inflammation in the neck in patients with chronic pain after whiplash injury), while others believe that the pain is psychological and or psychosocial.
Like all chronic pain there is no denying the psychological symptoms of chronic whiplash. Initially some patients may suffer shock and experience anxiety regarding their condition. Some may develop emotional side-effects such as depression, anger and irritability if their recovery time is lengthy. In some instances trauma counselling may be necessary. There is some evidence that psychological/ psychosocial treatments in conjunction with other rehabilitation treatments are useful for people with chronic whiplash.