Rupert Clements one of our chiropractors writes:
There is a fair old pile of misconception out there about what happens in whiplash and even the term is misleading with it now described far more accurately as cervical acceleration/deceleration, or CAD injuries.
The best study about the correct treatment for CAD injuries was put together by a study group called ‘The Quebec Taskforce’ who produced a report called Redefining Whiplash and its Management. One of the first things you’ll notice in the report is that they acknowledge that there’s a lack of evidence about what goes on in a whiplash and they were critical of the traditional treatment approaches. They set out a new approach to management of patients with whiplash induced cervical spine soft-tissue injuries and neck pain. These are:
1. Avoid rest, passive treatments and the use of a soft collar support – these approaches prolong pain and disability and lead to chronic or long-term problems.
2. Patients should keep as active as possible. Treatments that promote activity – such as manual treatments (joint manipulation and mobilization, soft-tissue techniques) and exercises should be used in combination with time-limited use of mild NSAIDs and or analgesics.
3. Avoid unproven therapies, including acupuncture, spray and stretch, transcutaneous electrical stimulation, ultrasound, laser, shortwave diathermy, heat, ice, massage, epidural or intrathecal injections, corticosteroid injections of the facet joints, muscle relaxants and psychosocial interventions.
Spritzer WO, Skovoron ML et al (1995) Scientific Monograph of the Quebec Task Force on Whiplash- associated Disorders: Redefining Whiplash and its Management, Spine 20:88.
And there was this approach to caring for whiplash which appeared in two leading multidisciplinary text books:
Rehabilitation of the Spine: a Practitioner’s Manual by Craig Liebenson and Conservative Management of Cervical Spine Disorders by Donald Murphy.
Liebenson, who is no slouch, says that there must be:
‘an integration of rehabilitation and manipulative therapy’ which involves ‘a comprehensive analysis of the locomotor system’ to understand the true causes of the problem and then a ‘specific prescription of manipulation and rehabilitation’.
But what’s going wrong?
Well, 90% of patients with chronic pain following whiplash have limited cervical ranges of motion and in about 60% of these the pain arises directly from facet dysfunction.
- Lord SM, Barnsley L et al. (1996) Chronic Cervical Zygapophysial Joint Pain after Whiplash. A Placebo-Controlled Prevalence Study, Spine 21(15):1737-1745.
Interestingly, this lot add that the diagnosis ‘cervical facet pain’, unrecognized by most family physicians/GPs is ‘extraordinarily common’ and ‘cannot be ignored any longer’.
The Quebec Taskforce thrashed through whiplash and they came up with a classification for whiplash that is still recognised as the best way to classify the condition. It is called the WAD (whiplash-associated disorders) grading system (a.k.a. Quebec Grading System) is now de rigueur in the scientific community. Though it has to be said that it looks scarily similar to an earlier bit of work (1993) which produced the Gargan and Bannister grading system in which grade A was an absence of symptoms; grade B symptoms were described as a “nuisance”; grade C symptoms were “intrusive”; and grade D symptoms were classified as “disabling”. Here it is:
Grade Clinical presentation
0 No complaint or physical sign
1 Neck complain of pain stiffness or tenderness No physical sign
2 Neck complaint and musculoskeletal signs (range of motion loss or tenderness)
3 Neck complaint and neurological signs
4 Neck complaint and fracture or dislocation
Scarily, up to 71% of patients who have chronic pain following whiplash have undetected vertebral end plate fractures at the spinal levels associated with the pain that were overlooked on standard medical imaging.
- Michael Freedman Dec 2001.
And Uhrenholt, Grunnet-Nilsson et al. carried out a systematic review of the literature on cervical injuries following traffic accidents leading to fatalities and found that 93.5% of minor lesions were missed by conventional radiographic examination, MRI and CT scanning.
- Uhrenholt, Grunnet-Nilsson et al. (2002) Cervical Spine Lesions after Road Traffic Accidents: A systematic Review: Spine 27(17):1934-1941