Week 8 a WADs

Question 1

Outcome for people who have WADs

Answer 1

• 50% don’t recover

* 30 % remain moderately to severely disabled

Question 2

What is whiplash

Answer 2

• Whiplash is an acceleration-deceleration mechanism
• of energy transfer to the neck. The impact may result
• in bony and/or soft tissue injuries which in turn may lead
• to a variety of clinical manifestations (Whiplash
• Associated Disorders)

Question 3

Biomechanics of WAD

Answer 3

• S shape just after impact
• Upper cervical flexion continues with lower cervical
hyperextension beyond physiological range of movement
(ROM)
• Secondary upper thoracic spine movement of superior
directed acceleration and extension /rotation

Question 4

Time needed to brace for whiplash

Answer 4

Maximum injury 75 ms post impact -200 ms required for

muscle bracing

Question 5

Bone pathology/red flags WAD

Answer 5

• Bone (red flags!!)
• Severe pain, high velocity accident, on-going severe pain
(esp. at rest), neurological symptoms

Question 6

Disc pathology after whiplash

Answer 6

Disc
• Rim lesions (anterior annulus)
• End-plate lesions
• Posterior protrusion ± radiculopathy

Question 7

Posterior elements

Answer 7

Posterior elements
• Z-joint (articular cartilage, synovial folds)
• Capsule & ligament
• Nerve tissue (dorsal root ganglia, spinal nerve root, brain

Question 8

Grade 0 WAD

Answer 8

No complaint about neck pain

No physical signs

Question 9

Grade 1 WAD

Answer 9

C/O neck pain and stiffness or tenderness
only
No physical signs

Question 10

Grade II WAD

Answer 10

Neck compliant & MS signs -  ROM &

tenderness

Question 11

Grade III WAD

Answer 11

Grade II + neurological signs including
↓DTR,s , muscle weakness, sensory
deficits

Question 12

Grade IV WAD

Answer 12

Neck symptoms + fracture/ or dislocation

Question 13

Criticisms of Qubec Task Force Classification

Answer 13

Some criticism of QTF system of classification since its release
• Guidelines adopted without scientific validation (Spine 1998, (23)
1043, Spine 2001, (26) 36-41, )
• Limited predictive capacity of the guidelines in terms of
recovery and non recovery

Question 14

Proposed adaptation QTF, WAD IIA

Answer 14

Neck pain
Motor impairment -decreased ROM, altered
muscle recruitment patterns (CCFT)
Sensory impairment

Question 15

Proposed adaptation QTF, WAD IIB

Answer 15

Neck pain
Motor impairment – decreased ROM
Sensory impairment ( local cervical mechanical
hyperalgesia)
Psychological impairment of elevated
psychological distress

Question 16

Proposed adaptation QTF, WAD IIC

Answer 16

Neck pain (severe initial)
Motor impairment (decreased ROM)
Sensory impairment
Local CX mechanical hyperalgesia
Generalized sensory hypersensitivity (mechanical, cold/thermal,
BPPT)
May show SNS disturbances : eg dizziness
Psychological impairment such as poor concentration
Psychological distress ( GHQ - 28, Tampa )
Symptoms of acute post-traumatic stress

Question 17

Specific assessments WADs

Answer 17

• GHQ-28 28 – general health
questionnaire
• BPPT – brachial plexus
provocation test = NTPT
• Cervical muscle dysfunction
(CCFT =cranio cervical
flexion test)
• Motor control of the
cervical spine movement

Question 18

Sensori-motor tests WADs

Answer 18

Sensori-motor tests:
• Balance
• Cervical spine joint position
error
• Eye follow
• Gaze stability
• GHQ 28

Question 19

Central hyperexcitability

Answer 19

• Reports of mechanical allodynia or
hyperalgesia: pain with touch, bedclothes
• Thermal allodynia: pain with cold, ice
• High irritability of pain
• Sleep disturbances)
• Sensory hypersensitivity (decreased pain
threshold).
• Brachial plexus provocation tests (bilaterally)

Question 20

What should you address in WAD treatment?

Answer 20

Address:
• Motor:
Improve ROM (joints and neural tissue)
Retrain deep neck flexors and extensors
• Sensori-motor: balance, head reposition, eye
follow, gaze.
• Psycho-social:cognitive, emotional &
behavioural factors

Question 21

Management of acute WAD

Grades I-III

Answer 21

• Crucial first 2-3 months
• Return to activity
• General and specific exercises
• Simple analgesics, TENS , acupuncture
• Education/ assurance/advice with coping
• Review of 8 studies: The evidence neither supports nor refutes
passive or active treatments (Cochrane review Verhagen et al
2007) (Sterling & Kenardy 2011)

Question 22

Management of acute WAD

Grades I-III

Answer 22

• Those with mod or greater pain and disability,
central hyperexcitability and elevated distress
• Care not to provoke
• More gradual and graded progression of activity
• More specific Tx
• Decrease pain
• Help with psychological distress
• Careful coordinated care with patient included in
decisions

Question 23

Management of Chronic WAD

Answer 23

• Manual therapy (Vicenzino et al 1998); lateral
glide (Sterling et al 2010)
• Multimodal (man ther, exs and advice) (Jull et al 2007)
• Active exercises for impairments and functional
goals
• Coordination exercises (eyes and head): pos
effect
• Medical interventions: injections
• Psychological interventions: CBT

Question 24

A sensorimotor approach for

managing WAD

Answer 24

• Joint position error
• Balance practice (add bouncing a ball, walking
with head turns)
• Eye head co-ordination exercises
• Gaze stability training
• Tailor the exercises to findings from
assessment

Question 25

• Predictive of poor outcome: WAD

Answer 25

– early presentation of post traumatic stress (PTS) (as measured
on Impact of Events Scale (IES) >25-26/45)/ psychological stress
– higher initial pain intensity (>/=7/10) & disability (NDI >30-40%)
– presence of cold hyperalgesia
– widespread sensory hypersensitivity eg sensitive to touch
(suggestive of abnormal central processing)
– SNS dysfunction (as measured by impaired peripheral
vasoconstriction)
– less consistently predictive of poorer outcome:
i)reduced Cx AROM ii)older age
– note: compensation not conclusive as predictor of poorer
outcome