Whiplash Injury: What factors influence prognosis?

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Whiplash can be defined as “an acceleration–deceleration mechanism of energy transfer to the neck. It may result from rear-end 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 called Whiplash-Associated Disorders”

Whiplash is one of the most debated and controversial painful musculoskeletal conditions. This is in part due to the often compensable nature of the injury and that a precise patho-anatomical diagnosis is not usually achievable. While the figures vary depending on the cohort studied, current data indicate that up to 50% of people who experience a whiplash injury will never fully recoverand up to 30% will remain moderately to severely disabled by their condition.

So what factors influence whether the acute whiplash injury will get better or not?

Sarrami et al (2017) in their systematic meta-review aimed to identify factors which predict outcome after acute whiplash injury. A meta-review is a systematic review of systematic reviews i.e. instead of looking at the included studies individually, it collates and appraises data from systematic reviews. They undertook  systematic search for all systematic reviews on outcome prediction of acute whiplash injury was conducted across several electronic databases. Twelve systematic reviews with moderate quality were subsequently included in the analysis.

Factors associated with the prognosis for people with whiplash injury were:

• Post-injury pain and disability (i.e., pain and disability that whiplash patients experience after a car accident), whiplash grades, cold hyperalgesia

• Post-injury anxiety

• Catastrophizing

• Compensation and legal factors

• Early use of healthcare

The authors highlighted that the level of post-injury pain experienced and the psycho-social factors such as catastrophising, anxiety and compensation and legal factors were associated with long term pain and disability. 

Factors not associated with prognosis of whiplash were

• MRI or radiological findings

• factors related to the car accident such as the direction of impact, the use of seatbelts or headrests, and the speed of the car at the time of impact

It must be emphasised that association or correlation does not imply causation. Therefore while there is evidence that litigation and legal representation are associated with poor outcomes and long term pain, it does not mean that litigation is the cause of the pain... it may equally be that patients who have poor outcome tend to seek legal representation and hence the positive association. 

But these findings clearly highlight:

1. Not to over-medicalise the early whiplash management - It is important to assess and evaluate whiplash injury early as per the Quebec grading. 

  • Grade 0: No complaints about the neck. No physical sign(s).
  • Grade I: Neck complaint of pain, stiffness or tenderness only. No physical sign(s).
  • Grade II: Neck complaint AND musculoskeletal sign(s). Musculoskeletal signs include decreased range of motion and point tenderness.
  • Grade III: Neck complaint AND neurological sign(s). Neurological signs include decreased deep tendon reflexes, weakness and sensory deficits..
    Grade IV: Neck complaint AND fracture or dislocation.

But once evaluation has been done and for Grade 0-2, advice for relative rest, activities and self-management is probably the best intervention. It is important to educate the patient about the nature of condition and advise them to continue to remain active. Grade III & IV do need immediate medical management. 

There is high level evidence that early implementation of active exercise has a positive effect on pain and disability. So a Whiplash Recovery Handbook provided to the patients either at A & E or by the GP may be useful in helping them understand the condition as well as starting to perform active exercises. 

Advice to “Act as usual” within tolerable levels for a WAD is effective in reducing pain and improving function, especially in the early stages after the injury.

Indications for further assessment by a Specialist

  • Grade IV WAD
  • Worsening signs and symptoms despite treatment
  • Signs and symptoms of VBI
  • Signs and symptoms of neurological involvement

2. Assess, evaluate and address psychosocial factors - After the physical injury, the second important elements which had clear evidence for association with long term outcomes were the psychosocial factors including catastrophising, anxiety and compensation and legal factors. 

Catastrophising is an exaggerated negative orientation toward actual or anticipated pain experiences. is a cognitive process characterized by a lack of confidence and control, and an expectation of negative outcomes. One of the patients I recently saw had a minor 2mm tear in his rotator cuff, but as he had been told by his consultant that he had a tear in his shoulder muscles, he had developed catastrophic perception about his pain and had become over protective of his pain, not even moving it slightly for the fear of worsening his muscle tear. Consequently, he developed frozen shoulder and while the initial tear wasn't significant, the subsequent pain and limitations he experienced were far worse. Such is the impact of catastrophic thinking. 

Catastrophising is also usually closely associated with post-injury anxiety. Patients who have high levels of anxiety tend to develop catastrohic thinking. Health psychologists recognize catastrophizing as a general pattern of emotional thoughts/beliefs in which chronic pain patients overestimate the degree of emotional distress and discomfort that may be caused by a stressful experience, such as being injured, and then overly focus on the negative aspects of pain caused by the injury. This can lead to hypervigilance and fear avoidance behaviour.

Various validation outcome measures are available to assess catastrophising and fear avoidance. I regularly use Tampa Scale of Kinesiophobia to evaluate the psychosocial impact of injury. Education and Advice may not be enough to address these psychosocial factors and counselling/ CBT may be required to address specific elements of these. 

3. Get the compensation issues settled - Compensation/ litigation issues have been consistently reported as being associated with poor outcomes in whiplash claims. Further recommendation in this area are beyond the scope of my practice, but it is fair to say that it is important for insurers as well as solicitors to address the liability issues at the earliest and sort out the compensation as applicable.

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