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TeemuLuoto

Whiplash Injury

Essentials

  • An acute whiplash injury is typically caused by a read-end automobile collision.
  • In a typical situation the patient's neurological and imaging findings are normal and no spinal injury can be established.
  • The pain may become chronic and and some patients may develop whiplash-associated disorder (WAD).
  • Neck symptoms preceding the injury and certain psychological factors increase the risk of chronic symptoms.
  • Appropriate instruction, maintenance and improvement of cervical mobility, and analgesia form the cornerstones of treatment.
  • Use of a cervical collar should be avoided.

Whiplash injury

  • Whiplash injury to the neck is caused by a sudden and uncontrolled backward jerking of the head followed by a forceful forward bend.
  • The injury typically occurs in a rear-end automobile collision but may be caused by other mechanisms, as well.

Whiplash-associated disorder (WAD)

  • A syndrome called whiplash-associated disorder (WAD) may develop after whiplash injury, with onset at the injurious event.
  • The criteria for WAD
    • The mechanism of injury described above
    • No cervical fracture, intervertebral disk prolapse or spinal injury
    • No objective neurological deficits
    • No imaging findings
  • The figures reported for the annual incidence of WAD vary greatly, from 28 to 834 per 100 000.
    • Its incidence is highest among 20- to 24-year-old women.
  • Most cases of WAD resolve within a few weeks but in 14 to 42% of patients the symptoms persist.
  • The time of onset of WAD symptoms ranges from a few hours to several days after the incident.
    • Typical symptoms include neck/shoulder pain (100%), headaches (78-86%), vertigo (41-48%) and numbness/tingling of the upper limbs (38-46%).
    • The neck is stiff and painful on movement.
    • Neurological findings are normal.
  • Nothing abnormal can be seen in cervical x-ray or CT images. MRI findings are also unspecific and unrelated to the nature or severity of symptoms.
  • The development of WAD is thought to be due to augmented nociceptive processing associated with tissue damage and to the development of sensory hypersensitivity (cf. fibromyalgia, for example Fibromyalgia).
  • Psychological factors (such as posttraumatic stress reaction Acute Stress Reaction and Post-Traumatic Stress Disorder, weak resilience, pain avoidance behaviour) play a role in the development of WAD.
  • Systemic inflammation process has been suggested to be related to the development of WAD. The blood interleukin-1 beta and tumour necrosis factor alpha concentrations have been found to be increased in people suffering from chronic neck pain.
  • Risk factors for WAD
    • Severe neck pain and/or headache immediately after the injury
    • Low level of education
    • Female sex
    • Neck symptoms before injury
    • Catastrophic thinking and a pessimistic view of recovery

Treatment

  • If symptoms following whiplash injury persist, it is important to exclude any treatable causes (fractures, traumatic disk protrusion, unstable cervical spine) and to confirm the diagnosis.
    • Cervical MRI is often necessary.
  • In the treatment of WAD, active mobilization and maintenance and improvement of cervical mobility are essential.
  • Appropriate instruction concerning the nature of the problem and safe mobilization promote recovery.
  • Psychological support should also be provided if there are signs of a posttraumatic stress reaction, for instance.
  • Mobilization can be carried out through a home exercise programme; a physiotherapist can help to plan and implement the programme.
  • The first choice analgesics are non-steroidal anti-inflammatory drugs and paracetamol; in the initial stage, short-term treatment with mild opioids can be considered in patients with severe pain.
  • Massage, kinesio taping and manipulation of the thoracic spine may be helpful.
  • Cervical collars, muscle relaxants and botulinum injections should be avoided.
  • Surgery does not bring benefits.
  • Chronic pain often constitutes an insurance law problem.

    References

    • Li Q, Shen H, Li M. Magnetic resonance imaging signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders: a meta-analysis of case-control studies. Eur Spine J 2013;22(1):14-20. [PubMed]
    • Michaleff ZA, Maher CG, Lin CW et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet 2014;384(9938):133-41. [PubMed]
    • Walton DM, Macdermid JC, Giorgianni AA et al. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. J Orthop Sports Phys Ther 2013;43(2):31-43. [PubMed]
    • Ferrari R, Russell AS, Carroll LJ et al. A re-examination of the whiplash associated disorders (WAD) as a systemic illness. Ann Rheum Dis 2005;64(9):1337-42. [PubMed]
    • Styrke J, Stålnacke BM, Bylund PO et al. A 10-year incidence of acute whiplash injuries after road traffic crashes in a defined population in northern Sweden. PM R 2012;4(10):739-47. [PubMed]
    • Carroll LJ, Holm LW, Hogg-Johnson S et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008;33(4 Suppl):S83-92. [PubMed]
    • Guidelines for the management of acute whiplash associated disorders for health professionals 2014 http://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/The%20APA/StatePAGES/TAS/TAS_Final-Guidelines-for-the-management-of-a~d-WAD-disorders-for-health-professionals-3rd-edition-2014-MAA32-0914-28-11-14a.pdf
    • Farrell SF, de Zoete RMJ, Cabot PJ et al. Systemic inflammatory markers in neck pain: A systematic review with meta-analysis. Eur J Pain 2020;24(9):1666-86. [PubMed]