---

Whiplash - W2.1

Definition of condition: Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck.  It may result from rearend or side-impact motor vehicle collisions, but can also occur during diving or other mishaps.  The impact may result in bony or soft-tissue injuries (whiplash injury), which in turn may lead to a variety of clinical manifestations.

Issue statement: The management of a whiplash injury should be geared towards early mobilization of the neck, a return to normal activities of daily living and work as soon as possible.  Residual disability after six weeks is an important warning sign of chronicity that justifies vigorous clinical intervention and mandatory interdisciplinary clinical consultation.  Moreover, the status of "whiplash syndrome" is a serious clinical development thus it is vital to prevent chronicity at all status of a whiplash injury.

WCB-Alberta position

Work relationship criteria

A work relationship can be established if the appropriate mechanism of injury is sustained during course of employment and/or performance of work duties.

Clinical criteria

Since whiplash injury presents with a wide array of signs and symptoms, WCB-Alberta adopts the following classification system in an effort to accurately assess the condition:

[Adapted from the Quebec Task Force on Whiplash - Associated Disorders 13]
Grade IV - Neck complaint AND fracture or dislocation are not covered by this guideline.

Clinical classification of Whiplash-associated disorders

Grade Clinical presentation

1. Neck complaint of pain, stiffness, or tenderness only
   No physical sign(s)
2. Neck complaint AND Musculoskeletal sign(s) *
3. Neck complaint AND Neurological sign(s) +
    

* Musculoskeletal signs include decreased range of motion and point tenderness.

+Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits.

Symptoms and disorders that can be seen in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain.

When assessing the clinical presentation, it is recommended that:

• a detailed history of the mechanism of injury be obtained
• the physician consider that psychosocial factors may affect the prognosis; the patient may require a specific approach towards evaluation and treatment

Diagnostic criteria

Recommended imaging:

• Grade II & III: baseline radiographic series to rule out fractures, dislocations,
• view of all 7 cervical vertebrae and the C7-T1 segment
• plain films with anteroposterior, lateral, and open-mouth views

Optional:

• - flexion, extension, and oblique views
  - tomography, computer-assisted tomography, and other imaging if the 3 plain view films are equivocal and/or there are signs and symptoms of neurological impairment regardless of the cause or if concerned about instability
• if significant signs and symptoms are persistent, cervical MRI

Recommend against:

• routine use of MRI, CT, and EMG/nerve conduction studies

Recommended Management

Education

Patient education by a treating physician or therapist is crucial to recovery.  The following points should be addressed with the worker:

• emphasize early return to usual activity and early return to work
• explain to patient how long symptoms can be expected
• reassure worker that there is no serious underlying cause for the pain
• emphasize the importance of postural and body mechanics control
• discourage extended dependence on health professionals

Physical methods of treatment

Physical therapy:

Grade I injury:  No formal physiotherapy program needed; thermal therapy applied by patient at home as tolerated.

Grades II & III injury: Formal program usually indicated. Start as pain is subsiding; may be intermittent, if indicated by patients needs, but should not continue beyond a maximum of 7 weeks (i.e., 21 visits). Other medical intervention can be offered after this time.

Recommended physio:  

As pain is subsiding:

• isometric exercises and gentle ROM within the limits of tolerance
• thermal therapy such as heat or ice as needed and tolerated by patient for pain relief.  Emphasis on positioning and postural maintenance is important.
• isometric exercises progressing to isotonic exercises usually within a few weeks with eventual progression to functional activities
• if no response to active physical therapy after 3 weeks refer back to treating physician for reassessment with possibility of further investigation, specialist referral or for FCE; there may be a need for direct contact between the MA and the attending physician re: management

Optional:

• use of cervical traction is not well established and should be decided on a case-by-case basis; discontinue early if no response
• laser therapy or TENS may provide transient pain relief but no lasting benefit
• acupuncture
• chiropractic treatment

Medical treatment

Drugs

Drugs have a limited role.  If indicated, they should  be used sparingly and be tailored to patients needs.

Recommended:

• analgesia as needed; if narcotic analgesia is required, should be tightly monitored and only used for 1-2 weeks

Optional:

• antidepressants
• NSAIDs &  muscle relaxants

Recommend against: 

Studies indicate that intraarticular corticosteroids and occipital nerve blocks have no scientifically proven efficacy.

Cervical Collar:

Recommended:

• intermittent use of appropriately fitted soft collar (for stable neck injuries)

Recommended against:

• continuous use

Note: use of a soft collar beyond the first 72 hours probably prolongs disability

Note: Grade IV injury: appropriately fitted molded collar (hard) for severe and unstable       injury

Referral to specialist:

Recommended:

• continued complaints and significant residual disability after 6 weeks (e.g., worker has not returned to work), are important warnings of chronicity and justify vigorous clinical intervention and mandatory interdisciplinary assessment

Optional:

• pain clinic
• referral multidisciplinary groups experienced in the management of whiplash injuries

Recommend against:

• psychologist/psychiatrist if not in conjunction with other forms of treatment

Surgical

Surgery is rarely indicated; if deemed necessary, it is likely that the condition is something more that a "whiplash" injury.  However, surgery may be performed for Grade III injury if there is progressive neurological deficit or persisting arm pain.

Fitness to work criteria

• Grade I injury: Immediate return to usual work activities; no work restrictionsExceptions:  Occupations requiring frequent use of neck e.g. crane or heavy equipment operator may require modified work duties.
• Grade II to III injury: Return to work as soon as possible; usually less than 1 week for grade II injury.  Temporary work restrictions may be prescribed
• primary care physician to reassess in three weeks if on temporary work restrictions or still off work

Permanent clinical impairment criteria

• No PCI expected with uncomplicated whiplash injury; a whiplash injury fully heals  with time.
• If PCI appears to be indicated, the condition is likely something other than whiplash (e.g. spinal cord injury, fractures, or dislocations) 
• refer to Permanent Clinical Impairment Guidelines

Patient care algorithm

The "Quebec Task Force on Whiplash-Associated Disorders"13 outlines the following algorithm as a guideline for patient care.  This algorithm has been included with the above "Medical Advisory Guidelines" to provide the Medical Advisor with another method of reviewing appropriate treatment for whiplash injuries.  Operational definitions are included to explain the terms used in the algorithm.

[ From: Spitzer, W.O., Skovron, M.L., Salmi, L.R., Cassidy, J.D., Dunaceau, J., Suissa, S., & Zeiss, E. (1995).  Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders: Refining "Whiplash" and Its Management.  Spine, 20(8S), 12-73.]

Table 18. Operational definitions

Isolated	Not associated with other injuries.
Obtunded	Dulled consciousness
Form	Recording information from the history and physical examination, management decisions, and grading of the WAD should be completed for all initial visits for Grade I-III and preferably on a standardized form (Appendix I).
History	Includes characteristics of patient, previous history of medical and other pertinent factors, including neck problems, circumstances and mechanism of injury, nature and time of onset of all symptoms, and self-assessment of health status.
Physical Examination	Inlcudes inspection, palpation, range of motion, neurologic examination, assessment of associated injuries, general health, and mental status; required details can be found on data form for all recommended visits (see form).
Plain radiographs	Include anteroposterior, lateral, and open-mouth views; all seven cervical vertebrae and the C7-T1 level should be included.
Reassurance	Patients should be reassured that most WAD are benign and self-limiting, and they should be encouraged to resume usual activities of life as soon as possible.
Prescribe activity	Interventions should focus on promoting activity. Range of motion excercises should be implemented. Techniques that promote mobility of the cervical spine can be used but should be applied by qualified personnel. Interventions that impede active mobilization of the neck are not indicated.
Return to usual activities	Patients should be advised to resume their activites of daily living (work, leisure, social, etc.) as soon as possible ( usually immediatly for Grade I). It should be explained to patients that usual activities may be temporarily painful but not harmed in WAD.
Unresolved	Unable to resume usual activities. A patient who still has residual pain or limitaion of range of motion but who is able to resume woark and other usual activities is considered to have resolved WAD.
Specialized Advice	Consultation with a health professional with in-depth formal training in managing WAD.
Reassessment	Includes history taking and physical examination as during initial visit and specialized advice as required.
Multidisciplinary team	Health professionals with in-depth training in

[back to top ]

---

Web site terms of use | Contact us