WHIPLASH INJURY

As a rule, but by no means exclusively, osteopaths and chiropractors address the issues of mobilisation of hypo-mobile seg- ments within the cervical and thoracic spine, whilst physiotherapists have become increasingly aware of the benefits of teaching exercises to enable the patient to “recruit” the deep stabilising muscles of the cervical spine.

Many practitioners now use “dry needling” which addresses trigger points and areas of hypersensitive musculature.

It is becoming increasingly obvious that these professions are gaining a wealth of experience from each other and there is a significant crossover of technique usage, providing each practitioner with a coher- ent armory of patient-specific approaches.

The musculoskeletal physician can provide the first point of contact and guidance to enable full benefit from the integrated approach. He or she can add in adjunctive treatments such as facet joint injections, nerve root injections, prolotherapy, drug therapy and cervical epidural injections. The musculoskeletal physician can also decide to recruit a clinical psychologist if it would appear that cognitive behaviour- al therapy should be added in to the treat- ment regime.

It has been shown consistently in ran- domised controlled trials that an early active management strategy is most effec- tive for whiplash-associated disorders, including return to pre-accident activity as soon as possible. Psycho-social inter- ventions, including cognitive behavioural therapy, can also help in achieving early activation.

Chronic symptoms can sometimes be

BOX 2: POOR PROGNOSTIC FACTORS IN WAD

■ Multiple symptoms early after injury

■ Increase in age ■ Young females have slower early progress

■ Neurological deficit in the first three days

■ Head position looking to one side at the time of impact

■ Pre-accident headache or neck pain www.sportex.net

treated with radio frequency de-nervation or prolotherapy injections but the relation between the symptoms and the injury may be uncertain.

It is also appropriate that educative advice is given to the patient and there is evidence that this is helpful in other mus- culoskeletal conditions. Evidence based patient education has been shown to be effective in shifting attitudes and proving clinical outcomes as well as reducing time lost from work.

The Quebec Taskforce (QTF) on whiplash- associated disorders suggested that infor- mation is an essential part of an active management approach and along with the British Columbia Whiplash Initiative (BCWI) this lead to the production of the Whiplash Book.

The Whiplash Book has been produced within the last two years based on the latest medical research and its effective- ness has been assessed in a study by McClune, Burton and Waddell. It conclud- ed that the book was found acceptable to patients and capable of improving beliefs about whiplash and its management. It seems suitable for use in the A&E envi- ronment and for wider distribution at population level. Only a randomised con- trolled trial would determine whether it has an effect on behaviour and clinical outcomes.

Encouragement of a favourable prognosis along with an early return to normal activity and work should be a major part of an active management programme. The ideal system is a physician co-ordinated, patient-centred, multi-modal approach

BOX 3: EARLY WARNING SIGNS OF PEOPLE AT RISK OF CHRONIC PAIN

■ Belief that you have a serious injury

■ Inability to accept reassurance ■ Avoiding movement due to fear of damage

■ Continuing to rest and avoid normal daily activities

■ Waiting for treatment to help, rather than believing you can help yourself to recover

■ Becoming depressed and anxious regarding the situation

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tailored to the patient, depending on the history, symptoms and signs of the pre- senting case. We use this system at The Blackberry Clinic in Milton Keynes.

RETURN TO WORK PROGNOSIS Most people can return to work 1-2 weeks after whiplash injury, especially if they are involved in manual labour. Light duties can be imposed as a transition and are important in providing motiva- tion to the patient.

The unclear prognosis of WAD is a major problem for clinicians and therapists, not only because it generates uncertainty in patient care but also because of the medico-legal requirements regarding insurance reports. Imaging studies of Grade 0-3 WAD have shown no convincing evidence of tissue injury.

In a study of medico-legal cases it was shown that 79% of cases returned to work within one month, 86% returned within three months and 91% had returned with- in six months.

It seems that patients who are sympto- matic after three months will remain so after two years or more, although their symptoms will fluctuate in this period. One further study suggested that most patients who still have symptoms two years after the accident will still have those symptoms at ten years, although their severity may change somewhat in the meantime.

Cultural differences may influence recov- ery since several studies have shown that cultures which do not have compensation and expectation of social support seem to avoid chronic pain after WAD.