Keywords: Whiplash associated disorder (WAD), Neck pain, Muscles, Physiotherapy, Special tests, Differential Diagnosis, NICE guidelines.
Clinically Relevant Anatomy
Whiplash is a muscle strain and/or ligament sprain within the neck. The most commonly injured muscles are the Sternocleidomastoid, Levator scapulae and Longus colli. In more severe cases of whiplash there can also be nerve damage and fractures of various processes of the cervical vertebrae.
People with WAD present a variety of symptoms occurring as a result of bony or soft tissue injury caused by whiplash injury to the neck during:
- An acceleration-deceleration mechanism of energy transfer to the neck
- A rear end or side impact motor vehicle collision
- A sporting accident e.g. in diving or rugby. (Adapted from Spitzer 1995)
- 300,000 new cases/ year.
- 500 cases per 100,000 per annum.
Characteristics and Clinical presentation
- Pain and stiffness in the neck which may not come on immediately but develop over the following 24 to 48 hours
- Reduced range of movement in the cervical spine (neck)
- Blurred vision (this should go within 24 hours, if they persist consult your doctor)
- Pain and stiffness may last a few days, to a few weeks, depending on the severity
- Severe pain in the back of the head
- Pins and needles or numbness in the shoulders or arms
- Memory loss
All of these symptoms could indicate a more serious injury or concussion. If any of these symptoms are present you should advise patients to return to the Doctor or hospital.
Healthcare professional or Physiotherapy management
- Visit your Doctor or hospital to get the neck checked for fractures and nerve damage
- Applying cold therapy can help relieve pain and inflammation in the first 24-48 hours
- A Doctor may prescribe painkillers or anti-inflammatories, such as ibuprofen
- Neck collars are not being used as widely now in the treatment of whiplash injuries because early mobilisation and range of movement exercises are being encouraged. This has been shown to decrease recovery time
- Try to gently move your neck in all directions as soon as you feel able to and on a regular basis (every couple of hours)
- Try to increase the range of movement each time
- All exercises should be within pain free limits
- After the acute phase (minimum 72 hours), manipulation and deep tissue massage may help restore normal function to the neck
- Stretching exercises for the neck can also be used, again provided they are pain-free
What do the NICE guidelines say?
As physiotherapists guided by the CSP we should be striving to base our treatments on a mixture of experience and high quality randomised controlled trials. The latest clinically guidelines for whiplash were completed in 2005. They recommend the following:
- Physiotherapists and people with WAD should be aware that serious physical injury is rare and a good prognosis is likely. Recovery is improved by early return to normal pre-accident activities, exercise and a positive attitude. Once a serious injury has been excluded, over-medicalisation is detrimental.
In the acute stage (0–2 weeks after injury) active exercise, education and advice on self-management and return to normal activity as soon as possible can be recommended. Manual mobilisation, soft tissue techniques, education about the origin of pain, advice about coping strategies, relaxation and transcutaneous electrical nerve stimulation (TENS) may be effective. There is no evidence to support the use of soft collars, traction, infrared light, interferential therapy, ultrasound or laser treatment.
In the sub-acute stage (2–12 weeks after injury) there is evidence to support a multimodal approach that includes postural training, manual techniques and psychological support. Combined manipulation and mobilisation, muscle retraining including deep neck flexor activity, acupuncture, education, advice about coping strategies, TENS, massage and soft tissue techniques may contribute to pain reduction and improvement of function.
In the chronic stage (more than 12 weeks after injury) exercise therapy, manipulation and mobilisation (which may be combined) and multidisciplinary psychosocial packages may be effective. Trained health professionals, who are not necessarily psychologists, can give psychological support.
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