Guideline
Title: WHIPLASH ASSOCIATED DISORDER
Document Author: Frances Hunt Date 03/03/2008 Ratified by: Frances Hunt, Head of
Physiotherapy
Date: 16.09.15
Review date: 16.09.17 Links to policies:
All SDHCFT strategies, policies and procedure documents.
1. Purpose of this document
To standardise the treatment of whiplash associated disorder.(WAD) 2. Guideline:
Applicability: All patients referred to physiotherapy over the age of 16 having sustained a whiplash associated disorder.
General principles
Serious physical injury is rare and good prognosis is likely. Recovery is improved by the early return to normal activities, exercise and a positive mental attitude. Once a serious injury has been exclude, over medicalisation is detrimental. WAD can also be complicated by a range of psychological factors.
Definition of Whiplash Associated Disorder. (WAD)
People with WAD present with a variety of symptoms occurring as a result of 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.
Epidemiology
Using Insurance statistics, current annual incidence of WAD in the UK is approximately 300,000 new cases/ year.
The total number of UK road traffic accidents remains stable, whist the number of insurance claims and WAD seen in A&E are increasing.
The incidence is approximately:
UK = 500 cases per 100,000 population per year.
Australia = 106 cases per 100,000 population per year.
Canada = 302 cases per 100,000 population per year.
Purpose of the Guidelines
Assess the quality of evidence available and make recommendations from this.
Make recommendations for future research.
Improve the quality of patient care by emphasising the best treatment options.
Lead to a more consistent approach to the management of WAD in the UK.
Methods
Evidence was derived from high quality research where this was available and consensus opinion where the literature was incomplete or equivocal.
The literature search was broad based not just confined to (randomised controlled trials (RCTs) or cohort studies. Systematic reviews were appraised. Inclusion criteria formulated and there was a final update search prior to publication. The RCTs were assessed for methodological quality using the same criteria as that used for PEDro (Physiotherapy evidence data base), the scale is based on a quality assessment tool developed by Delphi consensus. The levels of evidence used are those
recommended by the Chartered society of Physiotherapy (CSP) Information Paper
“Guidance for developing Clinical Guidelines”
To reach consensus on the literature, 4 options were selected - informal methods, the Delphi technique, the nominal group technique and a Consensus development Conference Recommendations were graded according to the type of evidence on which it was based.
The Recommendations
Recommendation – Mechanism of injury
“Physiotherapists should be aware of theories that are developing to explain mechanism of whiplash injury in order that they can relate the site of injury to the persons symptoms and plan their physiotherapy management.”
The term whiplash was first used in 1928 to describe an injury to the neck due to rapid acceleration-deceleration forces on the upper spine.
Recommendation – Classification
“The Quebec Task Force classification should be used by physiotherapists for WAD with grade 2 subdivided into 2a (point tenderness and normal range of movement (ROM)) and 2b (point tenderness and reduced ROM), in order to assist with diagnosis and prognosis.”
0 = No neck complaint. No physical signs.
1 = Neck complaint of pain, stiffness, tenderness. No physical signs.
2 = Neck complaint and musculo-skeletal signs (reduced ROM/tenderness).
3 = neck complaint and neurological signs
4 = neck complaint and # or dislocation.
Recommendation – Recovery
“Physiotherapists should advise people with WAD that they are very likely to recover.”
According to US data-
1/3rd of car occupants involved in an accident experience neck pain (33%) 1/3rd of these attend A&E (11%)
1/3rd of these consult their primary care practitioner (3%) 1/3rd of these develop chronic WAD (0.33%).
US data again –
60% report that symptoms subside after 1/12 and they are pain-free after 3/12 75% have recovered from symptoms after 6/12.
85% have recovered after 3 years.
Recommendation – Risk Factors
“Information should be sought about the following at assessment as they can adversely affect prognosis”
At the time of injury - Poorly positioned headrests,
Low relative weight of the vehicle that the person is travelling in, A rear end collision when the person is looking to one side.
Pre-injury -
Pre trauma neck ache, Degenerative changes, Low level of job satisfaction, Pre- trauma headaches.
Post-injury–
High initial pain intensity, Headache for more than 6/12, Neurological signs.
Recommendation - Barriers to recovery.
Compensation.
Occupational - perception of work and job content and working conditions
Psychological - fear of pain and movement, low self efficacy, severe anxiety, severe depression, low pain locus of control, high use of passive coping strategies, chronic widespread pain, high tendency to catastrophise.
Relationship difficulties, a series of previously failed treatments, non-compliance with treatment and advice.
Unrealistic expectations of treatment, inability to work due to pain, negative
expectations of treatment, poor understanding of the healing mechanism, failure of
the physiotherapist to meet the patient’s needs, poor clinical reasoning by the physiotherapist.
Ongoing moderate to severe symptoms 6/12 post injury may be associated with Post traumatic stress disorder.
Recommendation – Symptoms of WAD
Physiotherapists should be aware that the symptoms of WAD can include pain in the neck, shoulder, arm, tempero mandibular joint, headaches, generalised
hypersensitivity, paraesthesia and muscle weakness, visual disturbance, impairment of the proprioceptive control of head and neck position and cognitive function.
Recommendation – Physiotherapy assessment and examination Valid consent must be obtained
Access to service
Entry to the service should be prioritised by - screening individuals, providing a service in A&E and assessing individuals by phone.
Individuals who have their activities of daily life disrupted due to WAD, are unable to work due to WAD or who have a recent injury, must be prioritised.
Subjective Assessment
This must be thorough to plan examination and treatment.
Red Flags – bilateral paraesthesia, gait disturbance, spastic paraparesis, +ve Llhermittes sign, hyper reflexia,nerve root signs at more than 2 adjacent levels, progressively worsening neurological signs, symptoms of upper cervical instability, non-mechanical pain which is unremitting and severe. These must be referred to A&E for prompt investigation.
People with +ve stress test of the cranio-vertebral joints, vertebral column
malignancy or infection, past medical history of cancer/rheumatoid arthritis/long-term steroid use/osteoporosis/systemically unwell/structural deformity/instability or
hypermobility
should be treated with caution.
Physical Examination
Joint instability tests should only be conducted by a specially trained physiotherapist.
Cervical manipulation and pre-manipulative testing techniques should be avoided for people with WAD.
Physiotherapists need to know when special tests and investigations are indicated and how to carry out the tests or refer people appropriately.
People with WAD presenting with signs and symptoms of instability must be referred immediately for further investigations.
Inexperienced staff must know when to ask advice from senior staff.
Aims of treatment Improve function.
Empower the person with WAD.
Return to normal function/work.
Relieve symptoms.
Advising on pain relief.
Physiotherapists should refer to local guidelines for prescription of analgesia.
Where guidelines do not exist, physiotherapists and people with WAD should seek appropriate medical advice.
Recommendation – Treatment Acute stage 0-2/52
Soft collars are not recommended.
Manual mobilisation can be used to reduce pain, increase movement and function.
Exercise can be used to reduce pain and should commence within 4/7 of injury, Education and advice on self management, returning to normal activities, coping strategies and about the mechanism of pain.
Physical agents – consider transcutaneous nerve stimulation (TNS).
Insufficient evidence for; traction, infra red radiation(IRR),Interferential (IFT),ultra sound (US), laser, massage, acupuncture, megapulse.
Sub-acute stage 2/52-12/52
Manipulation/Mobilisation can be used to reduce pain and improve function BUT the risk of adverse effects may be increased following WAD.
Exercise – muscle retraining especially deep neck flexors may improve function.
Multi-modal approach – including postural retraining, manual techniques and psychological support to assist symptom reduction and return to full function.
Acupuncture – no evidence for or against.
Education and advice – coping strategies and to improve neck function.
Physical agents – consider TNS/massage/soft tissue techniques.
Insufficient evidence for traction, IRR, IFT, laser, US.
Chronic stage 12/52+
Manipulation/ mobilisation - consider both for pain relief and improved function.
Adding exercise therapy may be more effective.
Exercise therapy – combined with coping strategies may be more effective, consider group strengthening extension/retraction and proprioceptive exercises.
Multidisciplinary multi-modal packages may be more effective than traditional rehab.
Acupuncture – no evidence for or against.
Physical agents – no evidence for US, biofeedback, hot/cold, TNS, massage.
Recommendation – Education and advice Serious injury is rare.
Reassure about good prognosis.
Do not over-medicalise.
Recovery is improved by early return to normal activities, self exercise and manual therapy.
Positive attitudes and beliefs are helpful.
Collars, negative attitudes and beliefs and rest delay recovery and contribute to
chronicity.
Outcome measures relevant to WAD (not recommendations) Visual analogue score.
Neck Disability Index.
Physiotherapy Specific Function Scale.
MYMOP (Measure Yourself Medical Outcome Profile)
