Late Whiplash Syndrome: A Clinical Science Approach to Evidence Based Diagnosis and Management
From: Pain Practice, Volume 8, Issue 1, 2008 65–89
Late Whiplash Syndrome has been described as a disorder that is characterized by a constellation of clinical profiles including neck pain and stiffness, persistent headache, dizziness, upper limb paresthesia, and psychological emotional sequelae that persist more than 6 months after a whiplash injury. Because of the myriad of signs and symptoms with which the patient is capable of presenting, one must consider the many
possible different presentations the condition can produce.
Whiplash is the most common cause of neck pain associated with chronic musculoligamentous conditions. It is estimated that 6.2% of all Americans (approximately 15.5 million) currently suffer from Late Whiplash syndrome. Annual medical costs associated with whiplash injuries are estimated to range from $3.6 billion in the United Kingdom to $10 billion in the United States. The high incidence and exorbitant costs have elevated whiplash to international epidemic status.
Late Whiplash Syndrome involves a broad spectrum of symptoms ascribed to few other conditions or injuries
that may persist for months or years after the incident. It is estimated that only 10% of vehicle occupants exposed to a rear-end collision will develop whiplash syndrome. Of these, the incidence of chronic neck pain ranges from 18% to 40%. However, when whiplash symptoms do occur, a delay in symptom onset is expected. Selected studies have demonstrated that the delay in the onset of whiplash symptoms can range from 1 hour to several days after the accident. Moreover, patients that seek medical treatment for acute whiplash injuries face a 33% chance of developing Late Whiplash Syndrome at more than 30 months after injury. However, when presented with chronic symptoms and few causal factors, there is a tendency to suspect underlying nonorganic basis for the patient’s symptoms.
Structural damage that persists beyond the average healing time for soft-tissue injuries is not common among patients with whiplash. Thus, prolonged disability and limited treatment effectiveness have invoked
conflicting views on the role of psychological factors and litigation in a patient’s recovery. Various investigators have reported the medico-legal aspects of chronic whiplash and have challenged the organic causes for this disorder, exemplified by the strong association found between retention of a lawyer and delayed recovery from whiplash injury. Even worse, unresolved matters with an insurance provider are strongly associated with a poor outcome from whiplash associated disorders (WAD) as far out as 3 years after the injury. Thus, it has been contended that Late Whiplash Syndrome should be considered as much a behavioral disorder as a chronic injury.
The primary role of intervention must be centered on patient education, so as to improve the patient’s understanding of the symptoms related to tissue strain and muscle spasm while stressing the high probability of recovery. Clinicians must stress the importance of returning to normal activity for the sake of preventing the development of more disabling and persistent symptoms. Proper patient education is critical to aid patients in overcoming their fears, as the fears are often based on unsubstantiated concerns. The clinician must describe the difference between activities that simply “hurt” and those that are harmful. Detailed explanations regarding the underlying factors that sustain the patient’s pain generator(s) and lead to symptoms could aid the patient in recovery, where greater acceptance of pain can be associated with a significant decrease in multiple measurable domains: pain intensity, pain related anxiety, depression, and physical and psychosocial disability.
Studies of multimodal management for Late Whiplash Syndrome offer promising outcomes for management of persistent whiplash symptoms. Vendrig conducted a study of 26 patients with chronic whiplash symptoms (WAD I or II). All patients received intervention based upon a multimodal treatment program designed to restore normal daily activities and return to work with no real emphasis on pain reduction. The primary emphasis of the treatment regime involved operant conditioning with graded activity to eliminate inappropriate pain behaviors. At a 6-month follow-up, significant gains were observed in terms of pain intensity, activity tolerance, and return to work. However, more than 50% of patients did not demonstrate a clinically significant change and 35% did not return to work. The authors suggest that deep-rooted beliefs
about pain (avoid activity until symptoms resolved) impaired healing prognosis.
The patient’s individual coping style could significantly influence treatment outcomes. Obvious patterns of avoiding daily activities and nonharmful functions indicate a tendency to avoid, rather than confront, behaviors where the patient fears could result in pain. Proper patient education is critical to aid patients in
overcoming these fears, as they are often based on unsubstantiated concerns.
According to consensus-based recommendations from the Quebec Task Force on WAD, ROM exercises should be immediately implemented. A number of studies point to the importance of early activation as a preferred treatment program for acute whiplash patients. When asked about the best advice for acute whiplash patients, 90% of clinicians agreed that a return to normal activity, even if it produces symptoms, should be recommended and that exercise therapy is an effective treatment approach in these cases.
A systematic review of randomized trials concluded that there is no beneficial evidence for use of manipulation and/or mobilization as the sole treatment for mechanical neck pain. However, when these treatment procedures were combined with exercise, the effects are beneficial for persistent mechanical neck disorders with or without headaches. A prospective randomized clinical trial evaluated an active intervention program involving manual therapy and gentle exercise that resulted in reduced pain intensity, less sick leave, and improved neck ROM. These results suggested that an active intervention was more effective in reducing pain intensity and sick leave, as well as in retaining/regaining total ROM vs. the standard intervention for chronic whiplash patients.
The careful application of manual skills to encourage restoration of physiological articular motion is a valuable treatment tool for persistent neck pain associated with Late Whiplash Syndrome. The clinician must incorporate keen attention to the patient’s history to rule out the presence of any red flags or contraindications to mobilization. This pretreatment screening should include a thorough assessment of ligamentous instability and vertebral artery insufficiency, which have been previously described. After screening, manual therapy should be applied based upon the basic goals of reducing pain and/or restoring motion. The decision regarding which of these two therapy goals should be emphasized is based upon the severity of the symptoms and the specificity of the clinical profile. If the patient presents with minor symptoms of pain and stiffness, then the goal for manual therapy should focus on restoration of physiological spinal motion. However, a patient complaining of severe neck pain may best benefit from gentle manual techniques to reduce pain and sensitivity.
There is no consensus on the optimal approach for evaluation and management of Late Whiplash Syndrome.
The constellation of symptoms with which patients present must be evaluated using an in-depth history and thorough clinical exam. The order of treatment must be guided by a specific diagnosis that determines potential pain generators and contributing factors. A successful treatment regime involves a multidisciplinary
approach. As expected in any instance of chronic pain, there are factors related to psychosocial and behavior that have some impact on symptom presentation. Notwithstanding the need to screen patients for any precautions or contraindications to manual therapy, it is crucial that a conservative approach includes opportunities for the patient to accept an active role in their recovery.
