Synonyms

Whiplash-associated disorder

Definition

Whiplash clinical criterion is an injury to soft tissues of the cervical spine region sustained from rapid acceleration and deceleration forces to the head and neck. This is a common injury resulting from a motor vehicle crash, particularly rear-end collisions, but can also occur as a result of a fall or contact sports. The rapid back-and-forth movement of the head and neck is believed to injure muscles, ligaments, tendons, nerves, and, more rarely, other bony structures such as disks or vertebrae. The 1995 Quebec Task Force on Whiplash is widely cited because it provides a comprehensive discussion of whiplash and its management and outlines a grading system to characterize the heterogeneity and severity among acquired whiplash-associated disorders (WAD) (e.g., WAD range 0–IV) (Spitzer et al. 1995).

Current Knowledge

Natural History and Course of Symptoms

The incidence of whiplash injuries has increased dramatically since the beginning of the twentieth century because of the invention of the automobile and the development of a sophisticated transportation system. The current annual incidence rate of WAD in Europe and North America is at least 300 per 100,000 persons following motor vehicle crashes (Holm et al. 2008).

Whiplash injury results in acute neck pain and other symptoms such as reduced range of motion, headache, dizziness, paresthesia, weakness, visual complaints, and cognitive complaints (Sterner and Gerdle 2004). Not surprisingly, the mechanism of injury of whiplash can also cause a comorbid concussive brain injury, making it difficult at times to know the etiology of a patient’s presenting complaints, as whiplash and concussion have many overlapping symptoms. Although whiplash symptoms may resolve within several weeks to months post injury for many, up to 50% of persons with lower-grade injury (WAD I–III) report symptoms 1 year post injury (Carroll et al. 2008).

Although few would deny the validity of acute soft tissue injury associated with whiplash, there is considerable controversy about whether or not chronic whiplash disorders are biologically or psychosocially determined. This is akin to the debate regarding recovery and outcome following concussion. As in the literature for mild brain injury, there is growing evidence that chronic symptoms following whiplash are associated with biological (injury characteristics) and social-psychological (expectations, posttraumatic stress, depression, insurance and compensation system) variables (Kasch et al. 2011; Sterling et al. 2011). Discovering the factors that contribute to outcome is important, particularly given how frequent symptoms persist following whiplash injury (Carroll et al. 2008).

Regarding biological predictors of outcome, higher severity of initial pain and higher grade of injury may correlate with outcome following whiplash (Carroll et al. 2008; Kasch et al. 2008, 2011; Williamson et al. 2008). Psychological factors such as low self-efficacy, acute or posttraumatic stress-related disorders, dysphoria, passive coping, catastrophizing, and excessive pain behaviors (i.e., fear of movement) appear to negatively influence outcome (Carroll et al. 2008; Spearing et al. 2012; Sterling et al. 2011; Williamson et al. 2008). Reviews by Carroll et al. (2008) and Williams et al. (2007) provide more detailed discussion of chronic whiplash-associated disorders.

Treatment

Treatment for WADs are typically noninvasive, but medical or surgical techniques can be employed if deemed medically necessary (e.g., high-grade WAD injury) (Conlin et al. 2005). Although rest and immobilization techniques may be used to treat whiplash, studies also support the benefit of mobilization treatments. Providers also frequently use pharmacological interventions, such as muscle relaxers, nonsteroidal inflammatory medications, tricyclics, and other antidepressant agents, and physical therapy focusing on stretching, range of motion, exercise, and posture.

Management of whiplash may also incorporate alternative medicine and behavioral medicine components, such as massage, acupuncture, chiropractic intervention, or psychotherapy (Shearer et al. 2016; Sutton et al. 2016; Wong et al. 2016). Neuropsychological evaluation may be ordered for patients with comorbid concussions during their recovery to help inform return to work or to provide reassurance. Most pain specialists would agree that treatment approaches for whiplash should contain an amalgam of biological and psychosocial principles. Therapies may include education, relaxation, mindfulness, biofeedback, or cognitive-behavioral techniques. Psychological interventions may be helpful acutely (psychoeducation), but may be most important for addressing chronic or disabling symptoms. Just as with postconcussive syndrome, psychotherapeutic techniques for whiplash can (1) help patients with chronic symptoms manage pain perceptions through cognitive, behavioral, or psychophysiological (e.g., biofeedback) interventions; (2) teach patients how expectations can impact functioning, behavior and outcome; (3) improve coping skills; and (4) help patients resume prior psychosocial roles and responsibilities.

Cross-References