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Whiplash and whiplash-associated disorders (WAD) affect variable areas of the cervical spine, depending on the force and direction of impact as well as many other factors. Anatomic causes of pain can be any of these tissues, with the strain injury resulting in secondary edema, hemorrhage, and inflammation. The risk that patients develop WAD after an accident with acceleration-deceleration mechanism of energy transfer of the neck depends on a variety of factors.
If the patient was out of work before the accident, sick-listed, or had social assistance, this can also be associated with a negative evolution following whiplash trauma. Baseline disability had the strongest association with chronic disability, but psychological and behavioural factors were also important. Whiplash-associated disorders, is a complex condition with varied disturbances in motor, sensorimotor, and sensory functions and psychological distress.
One of the most common clinical characteristics is a restricted range of motion of the cervical spine.
Another characteristic is altered patterns of muscle recruitment in both the cervical spine and shoulder girdle regions.
Sensorimotor dysfunction is greater in patients who also report dizziness due to the neck pain.
It is important to carry out thorough spinal and neurological examinations in patients with WAD to screen for delayed onset of the cervical spine instability or myelopathy. Cervicoencephalic syndrome (CES) characterized by headache, fatigue, dizziness, poor concentration, disturbed accommodation, and impaired adaptation to light intensity. In comparison with the QTF classification, this system of classification incorporatesneuropsychological symptoms. Clinical diagnosisThe diagnosis of WAD remains clinical and the mechanism of the injury must be elicited.
MRI is not indicated at the time of initial presentation because of the high false positive results.
CT and MRI are generally used by patients with suspected spinal cord or disc injury, fracture or ligamentous injury. Canadian C-Spine Rule (CCR) is an algorithm to determine the necessity for cervical spine radiography in alert and stable patients with trauma and cervical spine injury.
The nociception input from the cervical facet joint can be modulated via radiofrequency neurotomy (RFN).The radiofrequency neurotomy is a neuroablative procedure used to interrupt nociceptive pathways and uses heat generated by radio waves to target specific nerves (medial branch emitted by dorsal ramus) and temporarily interfere with their ability to transmit pain signals from the facet joints. Botulinum Toxin-A (BTX-A) decreases muscle spasm that contribute to both pain and dysfunction.
The following surgical interventions can be used to treat chronical WAD if the non-invasive treatments (including multimodal physical therapy) did not provide satisfactory results. Indications for surgery include severe and prolonged headache, neck and radicular pain if the symptoms identified during the clinical examination are in agreement with the radiographic findings.
Whiplash-associated disorder is a debilitating and costly condition of at least 6-month duration. Treatment for acute whiplash can be delayed due to multiple social, economic, and psychological factors [82 [LOE:1A]] Psychological factors such as depression, anxiety, expectations for recovery, and high psychological distress have been identified as important prognostic factors for WAD patients. The target of education is removing therapy barriers, enhancing therapy compliance and preventing and treating chronicity. Oral Education: there is strong evidence for providing oral education concerning the whiplash mechanisms and emphasising physical activity and correct posture. Psycho – educational video: A brief psycho-educational video shown at the patient's bedside seems to have a profound effect on subsequent pain and medical utilisation in acute whiplash patients, compared to the usual care.
More studies are required to provide firm evidence for the type, duration, format, and efficacy of education in the different types of whiplash patients.
There is a difference between a patient suffering from acute whiplash and a patient suffering from chronic whiplash.
When behavioural therapy is used in the therapy, it decreases the patient’s pain intensity in problematic daily activities. Immobilization with a soft collar is less effective than active mobilization and no more effective than advice to act as usual.
It does not appear that providing educational information during the acute phase provides a significant measurable benefit. Limited evidence that active and passive interventions seemed more effective than no treatment.
Exercise programs are significantly more effective in reducing pain intensity over both the short and medium term. Moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders. Whiplash associated disorders (WAD) are a result of a previous whiplash injury and has a variety of characteristics and symptoms. This presentation, created by Omar Valdezm, Kimberly Whitcher, Heather Williams, and Carcy Wright; Texas State DPT Class.
The relationship between insurance claim closure and recovery after traffic injuries for individuals with whiplash associated disorders. Headaches affect just about everyone at some point in their lives and are one of the most common reasons people visit a chiropractor. The majority of recurrent headaches are of three types: tension, migraine, and sinus headaches.
Chiari malformation is a general term used to describe a condition when the bottom part of the cerebellum (the “tonsils”) dip down into the upper spinal canal.
If the upper certical vertebra (odontoid process of the second cervical vertebra) ascends into the cranial compartment (basilar invagination), the canal at the junction between the brain and spine can narrow. In rare instances high pressure in the brain compartment can “squeeze” the cerebellar tonsils downward.
In other rare instances, abnormally low pressure in the spinal compartment can “draw” the cerebellar tonsils downward. Weakness is also prominent, especially in the hands when there is associated syringomyelia.
Other symptoms include neck, arm, and leg pain, numbness, loss of temperature sensation, unsteadiness, double vision, slurred speech, trouble swallowing, vomiting and tinnitus (ringing in the ears). MRI is the diagnostic test of choice for Chiari I malformation, since it easily shows the tonsillar herniation as well as syringomyelia, which occurs in 20 percent to 30 percent of cases.
An MRI cerebrospinal fluid (CSF) flow study is often helpful for determining the impact of the Chiari malformation.
CT-myelogram for diagnosis of spinal CSF leaks for cases of suspected intracranial hypotension, or syringomyelia in the absence of Chiari malformation. In general, the surgical aim is to reestablish free flow of cerebrospinal fluid back-and-forth from the brain and spinal compartments.
The aim is to remove the back, lower part of the skull bone, plus the back of the first cervical vertebra. Removal of the odontoid (part of the second cervical vertebra) in cases in basilar invagination.

It may result from rear-end or side-impact motor vehicle collisions, but can also occur during diving or other or following other types of falls. In a study by Holm et al, it was demonstrated that one of the key factors for developing WAD is the severity of the impact. He also demonstrated that self-reported characteristics before the collision are important for recovery. Illness notification before the accident can also be associated with neck pain in the future. The number of people worldwide who suffer from chronic pain is between 2 and 58 %, but lies mainly between 20 and 40%. This finding may reflect underlying disturbances in motor function due to the initial peripheral nociceptive input caused by injured anatomical cervical structures. If the X-ray gives positive results for fracture or dislocation, the patient should be immediately referred to an emergency department or to a specialist surgeon. The examination procedure for patients with WAD is similar to the examination of the cervical spine. Animal studies have demonstrated that cervical facet joint injury may be responsible for hypersensitivity and increased neuronal excitability.Pain from the cervical facet joint can be medically managed using steroid injections to the specific zygopopsyal joints. The RNF can improve the pain, disability widespread hyperalgesia to pressure and thermal stimuli, nociceptive flexor reflex threshold, and brachial plexus provocation responses as well as increased neck range of motion one month and up to 3 months after the RFN. Pain and range of motion with patients with chronic grade 2 WAD improves 2 to 4 weeks post treatment [27 [LOE: 1B]].
Very often these patients do not fit into treatment categories as defined for other cervical pain problems due to multiple factors, and even within the WAD group there are multiple variances which warrant individualised treatment approaches.
It has better effect on pain, cervical mobility, and recovery, compared to rest and neck collars. There is a suggestion that the injury in combination with psychological factors may lead to chronic WAD.
Active mobilization is associated with reduced pain intensity and limited evidence that mobilization may also improve ROM, although it is not clear whether active mobilization is any more effective than advice to act as usual. No evidence exists to support the use of postural exercises for increasing neck range of motion. This clinical presentation can be divided into different grades, reported by The Quebec Task Force. Physical, emotional and chemical stressors can cause misalignments of the spine that irritate nerves and cause headache pain. Headaches can be alleviated by chiropractic manipulation and treatment that involves safe, specific adjustments particularly to the neck, upper back and spine to relieve nerve pressure, muscle spasm, and improve circulation to the brain.
Lux, with over 35 years of holistic chiropractic experience, can help your headache pain call 052-401-3838 to schedule an examination and treatment plan today.
In most cases the compartment of the brain holding the cerebellum (posterior fossa) is smaller than normal.
This widens the “bottleneck” in order to allow CSF flow around the “cork.” This decompression is often accompanied by a duraplasty, a procedure to expose the coverings over the cerebellum, thereby also widening the fluid space.
The impact may result in bony or soft-tissue injuries (whiplash-injury), which in turn may lead to a variety of clinical manifestations called Whiplash-Associated Disorders (WAD).
Another review with a high evidence level recommends that patients suffering from acute WAD “act as usual” and do early, controlled, physical activity within their tolerance level. According to Meeus et al., in acute patients oral information is equally as efficient as an active exercise program. Furthermore, studies show that oral education could be as effective as active physiotherapy and mobilisation. Different types of exercise can be considered for WAD, including ROM exercises, McKenzie exercises, postural exercises, and strengthening and motor control exercises. Conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders. In additional to traditional chiropractic, a variety of headaches respond very well to holistic therapies such as Applied Kinesiology, NET (Neuro-Emotional Technique), Acupuncture and Nutritional Therapy.
In acute whiplash, symptoms last no more than 2-3 months, while in chronic whiplash symptoms last longer than three months.
Anterior cervical fusion normally follows the cervical discectomy in order to stabilise the vertebrae. It is not clear which type of exercise is more effective or if specific exercise is more effective than general activity or merely advice to remain active [63 [LOE:1A]] Active treatment which consists of early active mobilisation that is applied gently and over a small ROM, and which is repeated 10 times in each direction every waking hour seems to be as effective at reducing the pain after the whiplash injury as on ROM.
Exercise programmes are the most effective noninvasive treatment for patients with chronic WAD, although many questions remain regarding the relative effectiveness of various exercise regimens. When a patient has a WAD several anatomical tissues can be affected, depending on the force and direction of the impact. Obelieniene et al., there is evidence that neck pain present before the accident is a risk factor for acute neck pain after collision.
Patients with acute WAD experience widespread pressure hypersensitivity and reduced cervical mobility. For more information on this refer to the section on chronic WAD.In acute whiplash patients, a short oral education session is effective in reducing pain and enhancing mobility and recovery.
There is also evidence suggesting that coordination exercises should be added to the treatment to reduce neck pain.Multidisciplinary therapy gives positive results according to the reductions of neck pain and sick leave reported.
Available data suggest that the combination of the injury with psychological factors such as coping style and explanatory style may lead to chronic WAD. Soderlund et al., where the aim was to compare two different home exercise programs in acute WAD, the result was that a home exercise programme, including training of neck and shoulder ROM, relaxation and general advice, seems to be sufficient treatment for acute WAD patients when used on a daily basis. To diagnose WAD radiographic images are not the norm, unless it concerns a WAD Grade III and IV. The increase is due in part to a higher number of cars on the roads, which in turn can lead to more accidents.
In addition, a whiplash profile has been developed with high scores on subscales of somatisation, depression and obsessive compulsive behaviour in patients with WAD. Further research is required to determine the efficacy and the role of invasive interventions in the treatment of chronic WAD [72 [LOE:1A]].
The anterior part of the vertebras are stabilised by a metal plate that provides additional stability. It’s more useful to make a clinical diagnosis based on the clinical presentation and anamnesis. However, this increase in prevalence is also due to the fact that there is a greater public awareness of WAD and therefore those affected are more likely to consult their doctor and therefore the number of patients seeking healthcare for whiplash is on the rise. Self-efficacy, a measure of how well an individual believes he can perform a task or specific behaviour and emotional reaction in stressful situations, was the most important predictor of persistent disability in those patients. It is not easy to tease out the effects of manual therapy alone because most studies used it as part of a multimodal package of treatment.Systematic reviews of the few trials that have assessed manual therapy techniques alone concluded that manualtherapy, such as passive mobilisation, applied to the cervical spine may provide some benefit in reducing pain, but that the included trials were of low quality. The most common interventions are steroid injections, radiofrequency neurotomy, botulin toxin treatment, cervical discectomy and cervical fusion.

The majority of all reported associated symptoms were mild at both baseline and during follow-up. Improvement in pain behaviour resulted in improved neck disability and increased pain-free movement performance and pain thresholds according to a pilot study.
Although there are a lot of medical interventions, a WAD can also be treated in a conservative way. The therapy of an acute whiplash should consist of education, where it’s made clear by the therapist to stay active and ‘act as usual’, and early physical activity and mobilization.
These can be subjectively reported by patients, and may include allodynia, high irritability of pain, cold sensitivity, and poor sleep due to pain.Objectively, the results of the neurological examination are hyporeflection, decreased muscles force and sensory deficits in dermatome and myotome. For the management of chronic whiplash there is strong evidence that a multidisciplinary therapy is effective.
The use of a collar stands in contrast with what is indicated in most of the studies; activation, mobilisation and exercise. The first ten visits included regional bilateral long-lever cervical spinal manipulation to temporarily decrease pain and increase ROM, and there after the structural rehabilitation care started.
Multidimensional associative factors for improvement in pain, function, and working capacity after rehabilitation of whiplash associated disorder: a prognostic, prospective, outcome study. A poorer outcome is generally predicted in patients with higher initial pain and disability as well as hypersensitivty (e.g. This treatment consisted in mirror-image drop table adjustments, mirror-image handheld instrument adjustments, mirror-image isometric exercise and mirror-image extension-compression traction for the reduction of the abnormal anterior translation posture of the head.
A simple test for including or excluding a fracture is to smite with the ulnar side of the fist on the spine. During a one week period participants had to record their average pain and disability in a diary, using the VAS scale. The results showed a significant difference between the groups, with positive effects on the prevalence of symptoms in the exercise therapy group compared to the collar group at six weeks. It is proven that early exercise therapy is superior to collar therapy in reducing pain intensity and disability for whiplash injury. Other studies also showed that exercise therapy gives a better pain relief than a soft collar. Detailed information on the clinical assessment of cervical motor function is available elsewhere.
The rationale for the evaluation of such features is to plan an individualised exercise program for each patient based on the assessment findings.” M. BINDER A., The diagnosis and treatment of nonspecific neck pain and whiplash, Eura Medicophys 2007, vol.
Prospective, randomised, controlled study of activity versus collar, and the natural history for whiplash injury, in Germany. World Congress on Whiplash-Associated Disorders in Vancouver, British Columbia, Canada, February 1999. The perception of pain and pain related cognition in subacute whiplash-associated disorders: its influence on prolonged disability.
Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. The course of symptoms for whiplash-associated disorders in Sweden: 6-month followup study. Efficacy of postural and neck-stabilisation exercises for persons with acute whiplash-associated disorders: a systematic review. Muscle trigger points, pressure pain threshold, and cervical range of motion in patients with high level of disability related to acute whiplash injury, J. Simple Educational Intervention to Improve the Recovery from Acute Whiplash: Results of a Randomised, Controlled Trial.
Positive Cervical Artery Testing in a Patient with Chronic Whiplash Syndrome: Clinical Decision-Making in the Presence of Diagnostic Uncertainty.
Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: design of a randomised controlled trial.
The Burden and Determinants of Neck Pain in Whiplash-Associated Disorders After Traffic Collisions: Results of the Bone and Joint Decade 2000 –2010 Task Force on Neck Pain and Its Associated Disorders. Managing Injuries of the Neck Trial (MINT): design of a randomised controlled trial of treatments for whiplash associated disorders.
Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial.
Whiplash associated disorders: a review of the literature to guide patient information and advice. Cervical radiofrequency neurotomy in patients with chronic whiplash: a study of multiple outcome measures. Active intervention in patients with whiplash-associated disorders improves long-term prognosis.
Early intervention in whiplash-associated disorders: a comparison of two treatment protocols.
Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury.
Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash: Pain Med. Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management.
A proposed new classification system for whiplash associated disorders-implications for assessment and management. Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Et al.,Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders?
A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2 – interventions for acute WAD. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 5 – surgical and injection-based interventions for chronic WAD. Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review.
Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck.

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