WAD: Identifying a Path From Acute to Chronic Pain

Let's discuss the whiplashed patient who presents to the chiropractic physician and the potential progression from an acute cervical injury to a chronic pain syndrome. It is my opinion that the evaluation and management of a whiplashed patient is complicated – in fact, convoluted and difficult to manage without a collaborating team of medical experts. Sterling supports my opinion with the following statement:

"Whiplash is a markedly heterogeneous and complex condition with varied disturbances in motor, sensorimotor and sensory function as well as psychological distress."¹

Chiropractic physicians who accept patients following a motor-vehicle incident are usually caring for patients suffering with post-traumatic spinal sprain and strain injuries. These patients don't present to DCs with a mild injury, but a moderate or severe injury. I believe our whiplashed patients are often subjected to a path from acute pain to chronic pain. Hence, we must be capable of providing not only a diagnosis and treatment plan, but also a prognosis that will reveal the potential for chronic pain.

A study published in the European Spine Journal demonstrated that cases with neck pain before the accident and a high degree of emotional distress from the accident have a 10-fold increased risk of developing chronic neck pain.² It is probable that patients presenting with a moderate sprain / strain of the spine, especially in the cervical spine, will heal with residual scarred tissues, myofascial trigger points and laxity of spinal ligaments.

A Case Study to Consider

Let's evaluate a putative case of a patient suffering with a whiplash injury and chronic pain. A 40-year-old female patient, with a previous history of neck pain following a fall from a horse while in her teens, presents with neck pain, headaches, and numbness in her index finger of the right, dominant hand following a rear-end collision. The incident took place three months prior to this initial visit. She expressed her chief concern as, "My neck is killing me!" and pointed to the midline and right side of the lower cervical spine as the area of pain.

The patient was the driver of a stopped vehicle. She was unaware of the impending, rear-end impact with her head turned to the right. She denied loss of consciousness, but was confused after the impact. Her vehicle had to be towed from the scene of the accident.

She was taken to the ER for examination and treatment. Radiographic examination was negative for fracture or dislocation. She was prescribed ibuprofen for a muscle strain and advised to follow up with her primary care physician if the pain persisted for more than seven days. She did not follow up with the physician because the pain resolved.

One month after the injury, the neck pain returned with the headaches and numbness in the right index finger whenever she typed on her computer. She is a professional writer, so she is concerned that she will not be able to work because the pain in the neck and head starts within 15 minutes of beginning work at the computer.

When asked to rate the pain on an 11-point numerical rating scale, she claims the pain is 100! She does have some relief of the dull, aching pain in the neck if she takes a hot bath and then a glass of wine.

What's Your Prognosis?

Based upon only the subjective data obtained with the history-taking process, what is your prognosis? Will she heal? Will her condition completely resolve? Will she progress from an acute cervical sprain/strain diagnosis into a chronic pain syndrome diagnosis?

Because she was experiencing continuous neck pain from the fall during her teens and the obvious emotional distress expressed with the pain rating of 100 out of 10, this patient is 10 times more likely to become a chronic pain patient. Management of her new condition is complicated by the fact that she has a "whiplash-associated disorder" and a prognosis of chronic pain syndrome.

Yes, she will heal within 3-12 months, but her condition will probably not resolve. She is a classic example of a patient who will progress from an acute, whiplash-type cervical injury to chronic pain requiring episodic care for many years.

Test Your Knowledge

1. In what year did Dr. Crowe first describe whiplash?

a. 1895
b. 1928
c. 1949
d. 1964

2. Whiplash-associated disorder is the least common non-hospitalized injury resulting from a motor-vehicle crash.

a. True
b.& False

3. Usually, whiplashed patients recover in 2-3 weeks.

a. True
b. False

4. Only 50 percent of patients fully recover from a whiplash-type injury.

a. True
b. False

Clinical Pearls

• Mild spinal strains and sprains with an overstretching or tear of up to 5 percent of the tissue should heal and recover within 3-4 weeks.
• Moderate sprains and strains with up to 50 percent tear of tissues will heal with residuals and without full recovery. Episodic care will be required to improve quality of life and maintain neuromusculoskeletal function.
• Whiplashed patients with a history of neck pain prior to current whiplash injury and emotional lability are 10 times more likely to experience chronic pain syndrome.

Quiz Answers: 1. 1928. 2. False. 3. True. 4. True.

References

1. Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother, 2014;60:5-12.
2. Kivioja J, et al. Neither the WAD-classification nor the Quebec Task Force follow-up regimen seems to be important for the outcome after a whiplash injury. A prospective study on 186 consecutive patients. Eur Spine J, 2008 Jul;17(7):930-935.