Whiplash Associated Disorders

Normal Anatomy

Facet joints are surrounded by a fibrous capsule and lined by a synovial membrane
Articular cartilage, menisci, synovial folds and adipose tissue are also present
The number of synovial folds and meniscoid structures located in the facet joint can vary from person to person and could be a contributing factor to pathology
The fibrous capsules are highly innervated by mechanoreceptors (types I, II, and III)
Large amount of muscles within the cervical spine

Pathology

Variety of symptoms following an acceleration/deceleration injury to the neck

Facet joint becomes injured
Surrounding muscle spasm occurs to protect the cervical spine
Prolonged immobility and muscle spasm can lead to fatty deposits occurring as early as 4 weeks
Nerve roots and/or brachial plexus can be irritated or compressed
Vertebral and carotid arteries may become damaged

Mechanism of Injury

Traumatic

Road traffic collision
Fall
Sporting injury
Music concert

Classification

Quebec Task Force (QTF)

· 0 – No complaint about neck pain. No physical signs

· I – Neck complaint of pain, stiffness or tenderness only. No physical signs

· II – Neck complaint. Musculoskeletal signs including

o Decreased ROM

o Point tenderness

· III – Neck complaint. Neurological signs including:

o Decreased or absent deep tendon reflexes

o Muscle weakness

o Sensory deficits

· IV – neck complaint and fracture or dislocation

Prognosis

· 50% will have ongoing symptoms for 1 year

· 25% will experience post-traumatic stress disorder

· Factors indicating prognosis may be poor

o Initial pain levels >5.5/10

o Initial disability levels: NDI > 29%

o Symptoms of post-traumatic stress

o Negative expectations of recovery

o High pain catastrophizing

o Cold hyperalgesia

Examination

Subjective

· Neck pain with referral

· Stiffness first thing in the morning

· Aching end of the day

· Sitting for long periods and rotations painful

· Restricted range of movement

· Cervicogenic dizziness

· Headaches

· Paraesthesia

· Pain catastrophizing

· Post-Traumatic Stress

Objective

· Reduced and painful ipsilateral rotation

· Global restriction in range of movement

· Poor quality of movement

· Reduced joint play/ segmental mobility testing

· Muscle spasm

· Reduced proprioception

· Poor cervical extensor and scapular muscle strength

Further Investigations

· MRI

Management

· Very poor quality research

· Education and advice consistently shown to be cost effective

· Exercise interventions, manual therapy and other modalities show inconsistent results

· Future research will look at “Active Behavioural Physiotherapy Interventions”

Conservative

· Reassurance, pain education, return to normality ASAP, relaxation techniques

· Pain Relief

o NSAID’s, Ice or Heat, Massage

· Restore ROM – Cervical AND Thoracic

o Cervical Rotation, Extension, Thoracic Extension and Rotation

o Soft Tissue, Joint Mobilisations, manipulation, stretching, exercise

· Restore Normal Muscle Activation

o Deep cervical extensors, deep cervical flexors, scapular upward rotators and posterior tilt

· Restore Normal Dynamic Stability and Proprioception

· Psychological interventions should be considered for those with signs of post-traumatic stress

Plan B

· Rarely considered

· Facet Injections

· Fusion

References

(Nederhand et al., 2002, Elliott et al., 2013, Rodriquez et al., 2004, Michaleff et al., 2014, Sterling et al., 2004, Sterling, 2014, Treleaven et al., 2005, Elliott et al., 2006, Elliott et al., 2009, Mercer et al., 2007, Chien and Sterling, 2010, Teasell et al., 2010, Rushton et al., 2011, Davis, 2013, Lamb et al., 2012, Walton et al., 2013, Castaldo et al., 2014)

Castaldo, M., Ge, H. Y., Chiarotto, A., Villafane, J. H. and Arendt-Nielsen, L. (2014) 'Myofascial trigger points in patients with whiplash-associated disorders and mechanical neck pain', Pain Med, 15(5), pp. 842-9.

Chien, A. and Sterling, M. (2010) 'Sensory hypoaesthesia is a feature of chronic whiplash but not chronic idiopathic neck pain', Man Ther, 15(1), pp. 48-53.

Davis, C. G. (2013) 'Mechanisms of chronic pain from whiplash injury', J Forensic Leg Med, 20(2), pp. 74-85.

Elliott, J., Jull, G., Noteboom, J. T., Darnell, R., Galloway, G. and Gibbon, W. W. (2006) 'Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis', Spine (Phila Pa 1976), 31(22), pp. E847-55.

Elliott, J. M., Kerry, R., Flynn, T. and Parrish, T. B. (2013) 'Content not quantity is a better measure of muscle degeneration in whiplash', Man Ther, 18(6), pp. 578-82.

Elliott, J. M., Noteboom, J. T., Flynn, T. W. and Sterling, M. (2009) 'Characterization of acute and chronic whiplash-associated disorders', J Orthop Sports Phys Ther, 39(5), pp. 312-23.

Lamb, S. E., Williams, M. A., Williamson, E. M., Gates, S., Withers, E. J., Mt-Isa, S., Ashby, D., Castelnuovo, E., Underwood, M. and Cooke, M. W. (2012) 'Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries', Health Technol Assess, 16(49), pp. iii-iv, 1-141.

Mercer, C., Jackson, A. and Moore, A. (2007) 'Developing clinical guidelines for the physiotherapy management of whiplash associated disorder (WAD)', International Journal of Osteopathic Medicine, 10(2), pp. 50-54.

Michaleff, Z. A., Maher, C. G., Lin, C.-W. C., Rebbeck, T., Jull, G., Latimer, J., Connelly, L. and Sterling, M. (2014) 'Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial', The Lancet, 384(9938), pp. 133-141.

Nederhand, M. J., Hermens, H. J., MJ, I. J., Turk, D. C. and Zilvold, G. (2002) 'Cervical muscle dysfunction in chronic whiplash-associated disorder grade 2: the relevance of the trauma', Spine (Phila Pa 1976), 27(10), pp. 1056-61.

Rodriquez, A. A., Barr, K. P. and Burns, S. P. (2004) 'Whiplash: pathophysiology, diagnosis, treatment, and prognosis', Muscle Nerve, 29(6), pp. 768-81.

Rushton, A., Wright, C., Heneghan, N., Eveleigh, G., Calvert, M. and Freemantle, N. (2011) 'Physiotherapy rehabilitation for whiplash associated disorder II: a systematic review and meta-analysis of randomised controlled trials', BMJ Open, 1(2).

Sterling, M. (2014) 'Physiotherapy management of whiplash-associated disorders (WAD)', Journal of Physiotherapy, 60(1), pp. 5-12.

Sterling, M., Jull, G., Vicenzino, B. and Kenardy, J. (2004) 'Characterization of acute whiplash-associated disorders', Spine (Phila Pa 1976), 29(2), pp. 182-8.

Teasell, R. W., McClure, J. A., Walton, D., Pretty, J., Salter, K., Meyer, M., Sequeira, K. and Death, B. (2010) 'A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 - overview and summary', Pain Res Manag, 15(5), pp. 287-94.

Treleaven, J., Jull, G. and LowChoy, N. (2005) 'Smooth pursuit neck torsion test in whiplash-associated disorders: relationship to self-reports of neck pain and disability, dizziness and anxiety', J Rehabil Med, 37(4), pp. 219-23.

Walton, D. M., Macdermid, J. C., Giorgianni, A. A., Mascarenhas, J. C., West, S. C. and Zammit, C. A. (2013) 'Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis', J Orthop Sports Phys Ther, 43(2), pp. 31-43.