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Manage the patient with whiplash

How is whiplash best managed?

What factors influence prognosis?

Are investigations of any value?

How is whiplash best managed?

What factors influence prognosis?

Are investigations of any value?

Whiplash remains a controversial topic inextricably associated with litigation.1

The term whiplash was first used in the medical literature by Davis in 1945,2 to describe cervical spine injuries resulting from hyperflexion of the neck and associated with extensor recoil because of the usual limited mobility of the area.

Diagnosis and management of whiplash is difficult, with poor correlation between accident history and patient symptoms, and widely variable outcomes.

Significant acute pain may be managed with any combination of analgesia, muscle relaxants and manipulative treatment. However, a sizeable minority of patients develop chronic symptoms that may require psychological support.

Investigation has little to offer outside the acute setting. Clinical judgement and experience is more important for doctors when managing their own patients or acting as medico-legal experts.

Mechanisms of injury

Whiplash typically follows low-velocity car accidents. It is a diagnosis of exclusion that does not encompass fractures or subluxations.

It follows a sudden acceleration or deceleration of the head, relative to the trunk, in any plane.3 In the most typical situation, a rear-end collision, the extensor recoil results in a hyperextension cervical injury. The back of the head will bounce off the head restraint, causing a hyperflexion that is anatomically limited by the impact of the chin on the chest.

The precise cause of pain is uncertain, but cadaver studies suggest that occipital pain is usually due to stretching of the C1 and C2 dorsal root ganglia, whereas lower cervical pain is caused by facet joint compression.4

Several factors are known to affect the severity of injury. The relative weight of the colliding vehicles is important, with the occupants of a lighter vehicle more likely to suffer injury.5

There is little correlation between visible vehicle damage and reported injury, and most injuries occur in the presence of trivial vehicle damage.5

One possible explanation for this is a change in bumper design over the past decade. Under pressure from the insurance industry, who faced high repair costs for relatively innocuous damage, manufacturers opted for bumpers flush with the rest of the bodywork and designed to disperse kinetic energy on impact. This has resulted in more ‘elastic' than ‘plastic' collisions, which may disadvantage car occupants by increasing sudden acceleration.6

Seatbelts may worsen whiplash by increasing hyperflexion, but they reduce the overall risk of more serious injuries.7 The head restraint is the most useful device to limit injury, but is often positioned incorrectly.8

For a given force, women have double the risk of whiplash injury compared with men. This is probably because of anthropometrical factors, in particular a relatively longer and more slender neck.7

Injuries are more severe when the head is turned at the point of impact,9 and less severe if there is prior awareness of a collision,10 which may be a reason collisions at the rear end are prognostically worse than the front end.7

Clinical features

Symptoms may occur within minutes or hours but invariably within 72 hours of the incident.11 Neck pain is the cardinal symptom. It may radiate to the occiput, shoulder and interscapular area, and there is often associated headache. Other features may be paraesthesia of the arms, and symptoms of mild concussion, such as dizziness and slight phonophobia. None of these clinical features is pathognomonic, although examination typically shows tenderness over the interspinous ligament and muscles, particularly the paravertebral and trapezius, some limitation of movement, and occasionally neurological signs such as diminished grip strength and upper arm reflexes. Most patients have a favourable outlook and recover fully within two months.

Investigations

Any investigations are likely to be radiological. Whether or not X-rays are taken is a matter of clinical judgement; they are not helpful routinely, but may be needed in the acute setting to exclude serious injury. A loss of lordosis is typically seen; degenerative change is common from early middle age and not attributable to whiplash.

MRI scanning has shown several abnormalities in whiplash patients, including ligament tears and disc herniations. However, the correlation with symptoms is poor.13

Treatment and prognosis

Mild cases may resolve without treatment in a few days. Oral analgesics are helpful early on and for up to four weeks in significant injury. Suitable treatments are ibuprofen 400mg tds, or diclofenac 50mg tds. Paracetamol 1000mg qds prn, or a compound analgesic, such as co-dydramol two tabs qds prn, may be given in addition, depending on the symptoms.

An acutely painful stiff neck may benefit from diazepam (2 to 5mg up to qds) for up to seven days post-incident as a muscle relaxant. However, this must be weighed against sedation and the patient should be advised not to drive.

Early mobilisation and exercises to prevent stiffness are advantageous.13 Soft collars should not be used as they may exacerbate stiffness and perpetuate the sick role.14

Manipulation, by a chiropractor or physiotherapist, or therapeutic ultrasound may help more severe cases but are not routinely required.

Factors that suggest prolonged symptoms and poor prognosis include:

• A history of neck pain
• Muscle spasm
• Neurological signs
• A history of anxiety or depressive illness.14

A review of the patient's medical records can help evaluate the degree that symptoms may be influenced by a history of soft tissue injury or psychosocial factors.

Whiplash can cause significant disruption to patients' lives, with 26 per cent of patients taking more than six months to return to full activity and about 10 per cent permanently disabled in some way.1 The presence of persistent symptoms of more than six months' duration has been termed ‘chronic whiplash syndrome'.

Most controversies regarding whiplash relate to the validity of chronic cases, and a shroud of litigation obscures its evaluation and management. Many authorities refute its existence – however, this is only one end of a spectrum of professional opinion.15

Conversely, a recent study evaluating outcomes in 3,500 patients has recognised the chronic course of many sufferers, and the authors suggest that whiplash-associated disorders ‘should not be viewed piecemeal, as a series of specific structural disorders, but rather as a more generalised illness, involving diverse symptoms reflecting pathology, psychological responses and the social context in which the illness occurs'.16

Outright malingering is rare, though clinical examination and investigation can neither confirm nor exclude it. Of greater importance are attitudes that subtly influence patient psychology, such as overly defensive medical practice: it is difficult to convince a patient that they have a minor, self-limiting illness days after they have been stretchered into casualty with a stiff collar for urgent X-ray.

Further evidence of this is the marked global variation in reported whiplash cases. Western societies, with a risk-averse culture, emphasis on material wealth and powerful legal (and medical) establishments, have high reported rates.15 In contrast, a retrospective case-controlled study from Lithuania showed no long-term disability in 71 people who were initially injured.17

Litigation is independently associated with poorer outcomes, irrespective of the financial award,15 and evidence exists that patients with resistant cases are better served by cognitive behavioural therapy than further physical treatments with diminishing returns.18

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