Clinical course of whiplash-associated disorder (WAD)

More than half of people with WAD recover well and are free of pain or disability 1 year after injury (Carroll et al 2008). However, this means that many others have more trouble recovering from their injuries. If physiotherapists could identify which patients would improve naturally over time and which ones would not, they could better manage the patient’s treatment in the early stages of recovery.

Sterling et al (2010) identified three recovery pathways following whiplash injury:

  1. 45% of patients who have initial mild levels of pain-related disability are predicted to have a good recovery
  2. 39% of patients who have initial moderate to severe pain-related disability are predicted to have moderate levels of disability at 1 year post-injury
  3. 16% of patients who have initial severe pain-related disability are predicted to have moderate or severe disability at 1 year post-injury

Key risk factors for poor recovery are initially higher levels of reported pain and initially higher levels of disability. Walton et al (2013) recommended that initial pain scores of >5.5 on a visual analogue scale from 0 to 10 and scores of >29% on the Neck Disability Index are useful cut-off scores for clinical use.

Other prognostic factors include:

  • Symptoms of post-traumatic stress
  • Negative expectations of recovery
  • High pain catastrophizing
  • Cold hyperalgesia

Ritchie et al (2015) developed and validated a clinical prediction rule for WAD. This predicted 2 recovery pathways following an acute whiplash injury:

  1. Ongoing moderate/severe pain and disability in the presence of baseline NDI scores of 40% or greater, age of 35 years or older, and a hyperarousal subscale symptom score on the Post-traumatic Stress Diagnostic Scale of 6 or greater.
  2. Full recovery in individuals less than 35 years of age with a baseline NDI score of 32% or less

Although further studies are needed to comprehensively validate this clinical prediction rule, results to date estimate that where the above criteria are met, the probability of ongoing moderate/severe pain and disability is 90%, and of full recovery is 80%. It must be noted that these studies included only patients with grade II WAD (Quebec Task Force Classification) who had musculoskeletal signs including decreased range of movement and point tenderness but not patients with neurological signs or fracture/dislocation.

Carroll L, Holm L, Hogg-Johnson S, Cote P, Cassidy D, Haldeman S, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD):results of the bone and joint decade 2000–2010 task force on neck pain and itsassociated disorders. Spine. 2008;33:583–592.
Ritchie C, Hendrikz J, Jull G, Elliott J, and Sterling M. External Validation of a Clinical Prediction Rule to Predict Full Recovery and Ongoing Moderate/Severe Disability Following Acute Whiplash Injury. J Orthop Sports Phys Ther. 2015;45:242–50.
Sterling M, Hendrikz J, Kenardy J. Developmental trajectories of pain/disabilityand PTSD symptoms following whiplash injury. Pain. 2010;150:22–28.
Walton D, MacDermid J, Giorgianni A, Mascarenhas J, West S, Zammit C. Riskfactors for persistent problems following acute whiplash injury: update of asystematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43:31–43.

Measuring effect – is this treatment really working?

Demonstrating the benefit of treatment is critical to determining if the most appropriate or effective approach is being used. Often it is assumed by both physiotherapist and patient alike that just because symptoms are improved, even temporarily, after treatment that it is doing them good and therefore worth continuing. This may not always be the case and using validated outcome measures is the best way of objectively quantifying, or measuring, an effect.

Which questionnaire is right?

A reliable, validated outcome measure is one that has been tested, and proven, to be an accurate measure of what it is attempting to measure e.g. how much function one has in their upper limb or how much their problem is affecting their lifestyle or work. That’s simple enough but there are so many different ones - how do we know which is the right one to use for any given patient? Some focus on just one aspect, others might combine several such as physical and psychosocial or both pain and impact on work.
Choosing the right measure should be based on answering questions most relevant for that person, these questions can best be determined after thorough examination and sometimes are not apparent initially. Considerations would be:

  • The stage of the condition – some questionnaires are best used early after injury and are helpful in identifying those that are at risk of becoming chronic or not getting back to work e.g. Orebro Musculoskeletal Pain Questionnaire or StarT Back
  • Assessing contributing factors – these may be aspects of the condition that are major barriers to progress such as the degree that psychosocial factors or fear avoidance are influencing or inhibiting recovery e.g. Fear Avoidance Belief Questionnaire or Depression Anxiety and Stress Scale
  • Diagnosis – certain conditions such as neuropathic pain can be identified with the use of questionnaires, this is important to ensure the best treatment is given and the most appropriate medical specialists are engaged e.g. Leeds Assessment for Neuropathic Symptoms and Signs or DN4
  • Prognosis – what is realistic to expect for this person individually in terms of goals? e.g. should they be back at work in 6 weeks or 6 months? e.g Patient Specific Functional Scale. Knowing what to expect is critical to knowing if progress is satisfactory
  • How much is this injury or condition limiting or ‘disabling’ this person? e.g. Oswestry Disability Index or Neck Disability Index

Establishing a baseline measure is important so that change can be monitored as soon as possible. Validated outcome measures are also very useful in determining if treatment is helping to maintain a level of functional capacity.