144. Evaluating and Treating Neck Pain Due to Whiplash

In this episode of PTs Snacks podcast, we dive into Whiplash Associated Disorder (WAD). Listeners will learn about the nature of whiplash, common causes, and the anatomical structures involved. We discusse how to effectively evaluate patients using various screening tools and questionnaires, and emphasizes the importance of differentiating WAD from other cervical spine traumas. The episode covers best practices for treating WAD through a multimodal approach that includes manual therapy, exercise, patient education, and nerve mobilization. Tips for practicing and screening for red flags are provided, along with insights on how to empower patients through education and active management.

00:00 Introduction to PTs Snacks Podcast
00:20 Understanding Whiplash Associated Disorder (WAD)
01:20 Epidemiology and Causes of Whiplash
03:41 Clinical Evaluation and Screening for Whiplash
06:26 Treatment Approaches for Whiplash
10:08 Patient Education and Reassurance
11:12 Conclusion and Additional Resources

Transcript

0:32

Hey everyone. Welcome to PTs Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapists, students who are looking to grow your fundamentals in bite-size segments of time. Now, today we're gonna cover something called whiplash associated disorder. So typically when we think of whiplash, we think of this in the neck. But before we get carried away, if you've listened to the show more than three times and you found it to be helpful, if you wouldn't mind leaving a review, that really makes the world of a difference. And for those who have already done so, thank you so much. But what we're gonna do today with whiplash. Is basically go over what exactly it is, what we think is the pain generator, how we evaluate for it, and how we treat it. So this information is coming from our clinical practice guidelines, as well as a few other resources. But when we are calling something whiplash associated disorder or wad it's not necessarily just someone who has a sore neck. It's specific to a complex injury that can have several impairments. And we're gonna cover more of that in detail, but we know that this is a big issue with neck pain in general. Patients make up 25% of all visits to outpatient physical therapy, which whiplash of that is a major contributor to that number. There are nearly 4 million rear end collisions per year. And only 1 million result in reported whiplash injuries. And of those involved in those injuries, 70% of those are women usually between 30 to 50 years of age. And that injury is more common in those with low physical activity jobs. Some fun facts there. How whiplash differs from other cervical spine trauma is essentially, a lot of cervical trauma comes from contact force, like hitting the head against the dashboard, or maybe someone took a dive in shallow water and hit their head on the bottom of the lake or whatever that surface was. But whiplash is caused from inertial forces that are applied to the head. So think of a rear end collision. The anatomic structures that can be pain Generators with this include the stern colleto, mastoid and longus choline muscles, the intervertebral disc, the facet capsule. Capsule and the anterior longitudinal ligaments have all been implicated as pain generators. And obviously this can be a little hard to dive into in your exam, but we wanna think about the active and passive stabilizers of the neck and being able to be mindful of what all is involved. Now here's why it's so important for us to get a good mastery over what exactly what Pasha is because while initially whiplash is an acute injury and it can take a couple days to manifest, about 30% of people are gonna go on to develop chronic symptoms that last longer than six months. And some even show that up to 12 months, 37% can still have pain. We will also potentially see physical changes with this in someone who has chronic neck pain from whiplash, reduced neck strength, decreased range of motion, sometimes 25 to 35% less range than someone who has no neck pain, as well as altered movement patterns due to fear or pain avoidance. So when somebody is walking in after a whiplash event, we want to make sure, especially after any sort of trauma that we're doing a thorough history and screening. So typically these patients will use tools. Questionnaires like Neck Disability index, pain rating scales, fear avoidant beliefs, questionnaire and just gives us a chance to evaluate how their pain is impacting daily life. We also wanna make sure that we're screening for red flags, things like vertebral bas insufficiency, or VBI. Fractures, some serious neurologic conditions. And especially with whiplash from any sort of trauma. We also wanna do some ligamentous instability screening, so we wanna be cautious. It needs to be. In our testing, we need to be sure that we are trying to capture as much information as possible, picking up on potential symptoms such as lightheadedness, dizziness, vertigo, auditory or visual disturbances, if they have any voice hoarseness temperature changes, sleep disparate headaches. What are their headaches like do they. Were they there before the car accident? Have they changed since then? And that way we can get as best possible a good picture of the patient that's in front of us now in our exam. Yes, we wanna screen out all of these. We do wanna screen out things. So there are several screening tools that we can use for vertebral fractures. You wanna use ligamentous instability tests like sharp's, purser and alar ligament testing. It's also good if you don't have a lot of reps with this to just practice on all your cervical patients so you can get an idea of what normal is.'Cause it made me a little hard to. When you have someone who's coming in with a lot of neck pain after trauma, it's scary. So it's best to not process all of that for the first time with someone who is maybe causing you to be a little bit more stressed. That would be my advice. You don't have to follow it though. But essentially beyond those, we're also taking a look at how is their neck range of motion? Do they have decreased neck range of motion, increased muscle guarding or spasms? Do they have any signs or symptoms of other things going on? Do we need to rule out things like radiculopathies or of course fractures? Things that could be mimicking their symptoms? We can also look at things like their deep neck flexor function with the cranio cervical flexion test. Look at their endurance with a deep neck flexor endurance test. And if there is any nerve involvement, we can also take a look at their upper limb tension tests, spurlings distraction things of that manner. So in terms of treatment, the best approach in our evidence is typically a multimodal treatment. So what that means is typically combining manual therapy, exercise, patient education, and when called for nerve mobilization. We do know that early active management beats immobilization. There's a lot of randomized controlled trials and meta-analyses that show that early repeated range of motion and advice to stay active, lead to better short and midterm pain and return to work outcomes much better than prolonged collar use, although they might be in a caller a couple days just depending on who is sending them to you or what. Who they've come across. Multimodal care is great. Not, we don't wanna just do one treatment alone, manual therapy and exercise and education has the most consistent improvements in pain, disability, and range of motion. And I can't tell you how many times I've seen only one or only other, and this is a judgment free zone because I don't know what patients are in front of you and what they look like. But these patients oftentimes are only. I'll see them given only stretches or really passive modalities. Things help calm things down and they're not given anything to help build their neck back up to strengthen their neck and build up those muscles.'cause this is like a muscle strain in a way, the whiplash injury. So we need to make sure that we are treating that because it is very common in a lot of studies have done MRI studies on the cervical extensor muscles and found a lot of fatty infiltration after these injuries. So we don't really want atrophy. We wanna build up those muscles. In terms of manual therapy there's been several studies that have shown thoracic manipulation can help improve pain in cervical range of motion, and it can be a safe alternative if a cervical thorac is contraindicated. Remember we did screen out some sort of cervical instability for a reason or VBI for a reason. If you're not really sure, it's better be on the safe side and also have them follow up with a specialist before you do anything crazy. And we don't always have to do thrust manipulations. It might be that your patient doesn't want you to, you should definitely listen to your patient in that case so you can use mobilizations. And those have been helpful too. Just. Even just for pain modulation and bringing things down doesn't have to be cranking on their neck. So using this upper cervical and upper thoracic mobile manual or manual therapy, paired with deep neck flexor training has been found to show greater gains in reducing pain disability and improving motor control than mobilization alone. So in terms of your exercises, looking at not just deep neck flexor and extensor endurance training scapular training. A lot of these patients can have pain that refers into the scapula, but you wanna screen and see is this coming from the neck? Is it also a shoulder issue? Two separate things or the same pain referral pattern, and that will help guide your treatment a little better. Also sensory motor and proprioception training for joint position error and ocular-motor control can be really helpful because in the clinical practice guidelines, this whiplash associated disorder is technically under motor control impairments for cervical pain. And then aerobic exercise can be really helpful for pain modulation and overall recovery support. If they have nerve symptoms, doesn't necessarily have to be a nerve conduction issue. It could be a nerve tension issue. So whether it's neurodynamics or something else. And then again, talking to your patient, educating them is a treatment in itself. Offering them reassurance, addressing whatever fears that they have and their beliefs about their expectations on if they're actually gonna get better or not. That's huge. So it is really helpful for patients to understand what exactly went wrong, how what you're going to do is going to help them to actually recover from that when you expect them to get better. And sometimes even just talking about how to use pain in a positive way, reframing it in a way of being able to use it as feedback rather than something to be scared of. It can help them feel like they've got a little bit more control over how their body responds in their treatment. So some things to consider. Yes, there's a lot of elements to whiplash associated disorder. But being able to better understand what exactly is going on and how to help them can really build up your comfort with the these patients. So if you have any questions, I know this is a very brief episode as they always are but I'd be happy to help you best that I can. Remember, I can't. If you are asking as a patient, I can't really treat you over an episode I'll help you the best that I can. But this podcast is for physical therapists specifically. But if you would like to reach out at PTs Snacks podcast@gmail.com, you're more than welcome to. And as a side note, if you're trying to renew your license soon and you need to get more CEUs, or you just wanna take a deeper dive into all of these topics be sure to check out Med Bridge. They are offering listeners over a hundred dollars off their year subscription and if you're student even more. So all you'd have to do is use the promo code in the show notes and you would have access to with their program. Hundreds, thousands. A ton of courses, webinars, they even have specialty exam prep for if you're taking an OCS or SES, things like that. And as well, there is even an option where if you are trying to create a. Home exercise program for a patient. They've got a level on their subscription where you can add exercises and send that to your patient and they're able to watch videos of it being done, all that kind of stuff. And that patient's less likely to lose a piece of paper that you printed off and now it's lost on their kitchen table under a pile of something. But yeah, check out the show notes for that and. Of course, let me know if there's anything you'd like more topics on in the future. Have a great rest of your day and until thanks time.