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Whiplash-Associated Disorder: Grades & Management

Whiplash-associated disorder (WAD) is the term given for the collection of symptoms affecting the neck that come about by an accident involving sudden acceleration–deceleration forces such as those seen in motor vehicle accidents (MVA). The impact may result in bony or soft-tissue injuries (i.e., whiplash injury), but may lead to WAD. Approximately 30%-50% of patients who have a symptomatic whiplash injury report chronic and widespread symptoms (i.e., WAD). WAD is associated with a significant burden on the individual and healthcare system. WAD is a classic example of a musculoskeletal injury in which there is often an apparent disconnect between the severity of injury and the severity of disability.

 

What structures are injured in whiplash-associated disorder?

The neck is a complex anatomical region with several inert and contractile tissues. Therefore, WAD affects a variety of anatomical structures in the neck. The amount of injury and number of tissues injured depends on the force and direction of impact as well as many other factors. The causes of pain in WAD can be due to any of these tissues, with strain injury resulting in secondary oedema (i.e., swelling), haemorrhage (i.e., bleeding), and inflammation:

  • Joints of the neck and surroundings: zygapophyseal joints, atlanto-axial joint, atlanto-occipital joint, thoracic spine, ribs and shoulder complex
  • Spinal structures: intervertebral discs and cartilaginous endplates of the cervical spine (i.e., neck)
  • Muscles of the neck and shoulder: sternocleidomastoid, levator scapulae, upper trapezius etc.
  • Ligaments: alar ligament, anterior atlanto-axial ligament, anterior atlanto-occipital ligament etc.
  • Bones: C1-C7 and sometimes thoracic spine (i.e., upper and middle back)
  • Nervous system structures: nerve roots, spinal cord, brain, sympathetic nervous system
  • Vascular structures: internal carotid and vertebral artery

 

How common is whiplash-associated disorder?

In Australia, the prevalence of WAD per 100,000 people is 106, which makes it a relatively common musculoskeletal disorder. The prevalence of WAD appears to be on the increase, particularly in the Netherlands: an increase from 3.4 in 1974 to 40.2 in 1994 per 100,000 people. This increase in WAD prevalence has been attributed to a higher number of motor vehicles on the road, which in turn leads to more MVA. However, this increase may 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, leading to an increase in patients seeking healthcare for WAD.

 

Risk factors for whiplash-associated disorder

The risk that someone will experience a WAD associated with a acceleration-deceleration force depends on a few risk factors:

  • Severity of the impact: speed, direction and severity of impact; however, it is difficult to obtain objective evidence to confirm this
  • Previous history of neck pain: neck pain present before the accident is a risk factor for acute neck pain after collision.
  • Gender: women seem to be slightly more at risk of developing WAD.
    Age: younger people (18-23 years old) are more likely to file insurance claims and/or are at greater risk of being treated for WAD

Recent studies have indicated that approximately 14-42% of the WAD patients are at risk of developing chronic complaints (i.e., longer than 6 months), and 10% of those have constant severe pain. If patient still have symptoms 3 months after the injury, they are likely to remain symptomatic for at least two years, and possibly for much longer.

 

Signs and symptoms of whiplash-associated disorder

WAD is a complex condition with changes in motor, sensorimotor, sensory functions and psychological distress. Common signs and symptoms include:

  • Restricted range of motion and stiffness of the cervical spine.
  • Altered patterns of muscle recruitment in the neck and shoulder regions
  • Mechanical neck instability
  • Loss of balance
  • Disturbed neck-influenced eye movement control
  • Sensorimotor dysfunction causing dizziness and tinnitus
  • Psychological distress
  • Post-traumatic stress disorder
  • Concentration and memory problems
  • Anxiety and depression, which is common in chronic WAD patients

 

Classification and grading of whiplash-associated disorder

The Quebec Task Force Classification (QTFC) provides a sound set of recommendations regarding the classification and treatment of WAD, which are used to develop a guide for managing WAD.

QTFC WAD

 

Physical management of whiplash-associated disorder

Conservative management strategies for patients with WAD is poorly researched in the scientific literature. Often these WAD patients do not fit into appropriate treatment categories based on other neck pain problems and many other factors and there can even be great variance within WAD groups. However, the positive effect of early mobilisation exercises on reducing pain and improving function in patients with acute WAD is well established in the scientific literature and should always be implemented in management strategies. Nonetheless, owing to the complexity, chronicity and severity of symptoms in WAD, multidisciplinary approaches are often required to effectively manage the multifactorial nature of WAD.

1. Acute WAD

In acute WAD, treatment can be compromised by several social, economic and psychological factors. Depression, anxiety, expectations for recovery, and high psychological distress are important prognostic factors for WAD patients. Management initially involves:

  • Psychosocial factors. Diverting attention away from neck pain and dysfunction, increasing activity and independence, and patient education and reassurance.
  • Physical factors. Gentle neck range of motion/mobilisation exercises, soft tissue massage and heat therapy.
  • Ancillary care. Non-steroidal anti-inflammatory medication, ultrasound therapy

2. Chronic WAD

Chronic WAD is quite different to acute WAD, in that the initial phase of tissue trauma may have resolved, and yet the patient is left with disability, psychological factors and chronic pain. Activities of daily living, such as self hygiene, driving a car, shopping and exercise may be compromised due to several biopsychosocial factors causing a sensitisation ‘wind-up‘ that is seen in chronic pain patients.

A multidisciplinary approach has shown to be effective in the management of chronic WAD patients. This may include:

  • Cognitive therapy. Recognition of ability and encouraging positive effect by reappraisal, benefit finding and scheduling of positive activities.
  • Behavioural therapy. Practically applying what is conceptualised in cognitive therapy, such as encouraging activity engagement, pursuit of goals and facilitating present-focused awareness and skills to overcome challenging situations, thereby improving patients ability to adapt and self-manage.
  • Physical therapy. Neck range of motion and strengthening exercises, soft tissue massage and stretching and dry needling therapy.

 

More information

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Chris Knee

Chris is an experienced and qualified chiropractor, sports chiropractor, McKenzie Credentialed practitioner, nutritionist and Certified Strength and Conditioning Specialist (CSCS) and is finishing of his Doctor of Physiotherapy at Macquarie University.

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