Whiplash: diagnosis, treatment, and associated injuries
Sanjay Yadla Æ Æ John K. Ratliff Æ Æ James S. Harrop
Published online: 6 November 2007
? Humana Press 2007
literature. Objective To identify and synthesize the most
current data pertaining to the diagnosis and treatment of
whiplash and whiplash-associated disorders (WAD), and to
report on whiplash-related injuries. Methods A search of
OVID Medline (1996–January 2007) and the Cochrane
database of systematic reviews was performed using the
keywords whiplash and WAD. Articles under subheadings
for pathology, diagnosis, treatment, and epidemiology were
chosen for review after identification by the authors.
Results A total of 485 articles in the English language lit-
erature were identified. Thirty-six articles pertained to the
diagnosis, treatment, epidemiology of whiplash, and WAD,
and were eligible for focused review. From these, 21 pri-
mary and 15 secondary sources were identified for full
review. In addition, five articles were found that focused on
whiplash associated cervical injuries. These five articles
were also primary sources. Conclusions Whiplash is a
common injury associated most often with motor vehicle
accidents. It may present with a variety of clinical mani-
festations, collectively termed WAD. Whiplash is an
important cause of chronic disability. Many controversies
exist regarding the diagnosis and treatment of whiplash
injuries. The multifactorial etiology, believed to underly
whiplash injuries, make management highly variable
between patients. Radiographic evidence of injury often
cannot be identified in the acute phase. Recent studies
suggest early mobilization may lead to improved outcomes.
Ligamentous and bony injuries may go undetected at initial
Study design Focused review of the current
presentation leading to delayed diagnosis and inappropriate
Whiplash associated disorders (WAD) ?
Cervical spine injury
The Quebec task force (QTF) on whiplash associated dis-
orders (WAD) defined whiplash as ‘‘bony or soft tissue
injuries’’ resulting ‘‘from rear-end or side impact, predomi-
nantly in motor vehicle accidents, and from other mishaps’’
as a result of ‘‘an acceleration-deceleration mechanism of
energy transfertothe neck’’.Whiplashisassociated with
neck stiffness, arm pain and paresthesias, problems with
memory and concentration, and psychological distress. This
group of symptoms and signs are collectively termed WAD.
The QTF developed a classification system for WAD based
on severity of signs and symptoms (Table 1).
Whiplash is the most common injury associated with
motor vehicle accidents, affecting up to 83% of patients
involved in collisions, and is a common cause of chronic
disability [2, 3]. The overall economic burden of whiplash
injury, including medical care, disability, and sick leave, is
estimated at $3.9 billion annually in the US . If litigation
is included, the costs are greater than $29 billion . The
incidence of WAD is widely variable in the literature. In
the US, it is estimated at 4 per 1,000 persons .
The most recent literature suggests that whiplash injury
may occur as a result of hyperextension of the lower cer-
vical vertebrae in relation to a relative flexion of the upper
cervical vertebrae, which produces an S-shape of the
S. Yadla (&) ? J. K. Ratliff ? J. S. Harrop
Department of Neurological Surgery, Thomas Jefferson
University Hospital, 909 Walnut Street, 3rd Floor, Philadelphia,
PA 19107, USA
Curr Rev Musculoskelet Med (2008) 1:65–68
cervical spine at the time of impact . This differs from
the normal physiology where motion of the cervical spine
begins with the upper vertebrae. This theory suggests an
abnormal physiologic basis for the development of whip-
The current review provides a summary of recent liter-
ature focused on the diagnosis and treatment of whiplash
injury and WAD. In addition, we offer a focused review of
whiplash associated cervical injuries including ligamentous
injury, loss of lordosis, and fractures of the superior
A search of OVID Medline (1996–January 2007) and the
Cochrane database of systematic reviews was performed
using the keywords whiplash and WAD. Articles under
subheadings for pathology, diagnosis, treatment, and epi-
demiology were chosen for review after identification by
the authors. Additional sources not identified by the primary
search were obtained by cross-referencing bibliographies.
A total of 485 articles published from 1996 to 2006 in the
English language were found. Thirty-six articles were
identified for focused review pertaining to the diagnosis,
treatment, and epidemiology of whiplash and WAD.
Twenty-one primary sources were identified, and 15 sec-
ondary sources were identified for review. In addition, five
articles were identified that focused on whiplash associated
cervical injuries. All five articles were primary sources.
Many controversies exist regarding the diagnosis, treat-
ment, and prognosis of whiplash injuries. The wide variety
in the number of patients reporting injury and the inability
in many cases to find firm diagnostic evidence of injury has
led many to question the authenticity of whiplash injury
and WAD .
The diagnosis of whiplash remains clinical. The mecha-
nism of injury must be elicited. The clinical syndrome of
whiplash and WAD includes neck pain or stiffness, arm
pain and paresthesias, temporomandibular dysfunction,
headache, visual disturbances, memory and concentration
problems, and psychological distress. There are no specific
neuropsychological studies or electrophysiological tests
that can diagnose whiplash injury .
A wide variety of psychosocial symptoms may be
associated with whiplash including depression, anger, fear,
anxiety, and hypochondriasis . A so-called whiplash
profile has been described, which includes high scores on
subscales of somatization, depression, and obsessive-
compulsive behavior in patients with WAD .
Injury most often is not identified radiographically in the
acute phase . A prospective study of 100 patients with
normal plain radiography and no neurologic deficit evalu-
ated MRI findings of the brain and cervical spine within
3 weeks of injury . Only one patient had findings
associated with trauma (prevertebral edema).
The most common radiographic findings associated with
whiplash injury are preexisting degenerative disease or
slight loss of the normal lordotic curve of the cervical spine
. Flexion-extension X-rays at the time of injury may also
reveal a kyphotic angle. It is postulated that this is due to
hypermobility at a level adjacent to a level of hypomo-
bility, secondary to muscle spasm .
A prospective study of 39 patients with grade two to
three whiplash injury who underwent MRI within a mean
of 11 days from injury and a follow-up MRI after two
years found that 33% (13 patients) had medullary or dural
impingement by cervical discs . At two year follow-
up, all patients with medullary impingement (seven
patients) had persistent or increased symptoms and three
patients with no or slight changes on MRI had persistent
At the time of initial presentation, MRI is not indicated
because of high false positive results. CT and MRI are
generally reserved for patients with suspected disc or spinal
cord injury, fracture, or ligamentous injury. CT and MRI
may also be indicated in patients with long term persistent
Table 1 QTF classification of whiplash-associated disorders1
0No complaint about the neck. No physical signs
INeck complaint of pain, stiffness or tenderness only.
No physical signs
IINeck complaint and musculoskeletal signs. Musculoskeletal
signs include decreased range of motion
and point tenderness
III Neck complaint and neurological signs. Neurological
signs include decreased or absent deep tendon reflexes,
weakness and sensory deficits
IVNeck complain and fracture or dislocation
Adopted from Ref. 
66Curr Rev Musculoskelet Med (2008) 1:65–68
arm pain, neurologic deficits, or clinical signs of nerve root
Treatment in the acute setting
Whiplash injuries are difficult to treat for many reasons.
Patients may have subjective complaints of pain or pares-
thesias without any radiologic or clinical evidence of
injury. Complex interactions of psychosocial, legal, and
physical factors make effective treatment highly variable
among different patients. Initial treatment has traditionally
included a soft cervical collar to restrict cervical range of
motion. More recent studies suggest, however, that early
mobilization may lead to improved outcomes and that rest
and motion restriction may hinder recovery .
Rosenfeld et al. followed 97 patients exposed to whip-
lash trauma over a three year period prospectively. The
patients were randomized either to an early intervention
using frequent active cervical rotation or to a standard
intervention of initial rest, recommended soft collar, and
gradual self-mobilization. Patients who received active
intervention had significantly reduced pain intensity and
sick leave at 6 months and 3 years respectively . In
addition, patients receiving early active intervention had a
total cervical range of motion similar to that of matched
uninjured controls at 3 year follow-up.
Other investigations have focused on medical interven-
tions at the time of presentation with data extrapolated
from spinal cord injury studies. A randomized, placebo-
controlled study evaluated the efficacy of high dose ste-
roids given within 8 h of injury. In this study, treatment
subjects received a bolus dose of 30 mg/kg per hour given
over 15 min followed by a 23 h maintenance dose of
5.4 mg/kg per hour . Patients were followed over a
6 month period. Those receiving steroid therapy had sig-
nificantly fewer total sick days, and fewer disabling
symptoms compared to controls.
Treatment in the chronic phase
The QTF review did not report on evidence regarding the
independent benefit of exercise in chronic WAD. Studies of
patients with chronic neck pain, not necessarily motor
vehicle related, suggest that exercise and mobilization may
improve long-term outcomes.
A prospective uncontrolled study of patients with Type I
and Type II whiplash followed patients through a multi-
modal treatment program
therapy, and occupational therapy. Vendrig et al. found
that at 6 month follow-up, 65% of subjects reported com-
plete return to work, 92% reported partial or complete
including exercise, group
return to work, and 81% reported no medical or para-
medical treatments over 6 months .
Bunketorp et al. analyzed 47 patients involved in an
ongoing randomized controlled trial. Multiple regression
analysis found that self-efficacy, a measure of how well an
individual believes he can perform a task or specific
behavior and emotional reaction in stressful situations, was
the most important predictor of persistent disability in
patients with WAD .
The use of cervical radiofrequency neurotomy (CRFN),
a neuroablative procedure used to interrupt nociceptive
pathways, has been supported by several studies in patients
with chronic WAD. Prushansky et al. conducted a pro-
spective study of 40 patients with chronic whiplash injury-
associated disorders who underwent CRFN treatment. The
authors found an improvement in 70% of patients based on
a number of parameters including Neck Disability Index
and cervical range of motion .
Many other therapeutic interventions have been sug-
gested including temperomandibular
cervical traction, intraarticular corticosteroids, and botul-
inim toxin. The QTF concluded that scientifically rigorous
evidence to support their use is currently lacking .
Studies of long-term outcome for patients with whiplash
and WAD offer widely variable rates of recovery. Most
studies suggest persistent symptoms in 25–40% of patients
after 1 year . Other studies have reported symptoms in
as high as 39.6% of patients as far as 7 years after injury
A number of factors have been consistently associated
with delayed recovery including female gender, older age,
initial intensity of neck pain, neurologic deficit, preexisting
neck pain . In a retrospective cohort study from Dufton
et al., several factors associated with minimal clinical
change from initial presentation to follow-up were identi-
fied. These included older age, female gender, higher initial
pain intensity, lawyer involvement, and work status at time
of follow-up .
The variability in recovery in WAD is a source of
considerable controversy. The multivariable nature of
WAD suggests that further investigations of clinical,
demographic, and psychological factors are warranted in
order to improve treatment outcomes.
Whiplash associated cervical injuries
The QTF report focuses on patients with WAD Grade I
through III injuries following a motor vehicle collision.
Curr Rev Musculoskelet Med (2008) 1:65–6867
Grade IV injuries, which include patients with neck com- Download full-text
plaints and fracture or dislocation, were not specifically
addressed. The literature is peppered with case reports of
patients with WAD and missed fractures on presentation
. The most common radiographically identified abnor-
malities are loss of cervical lordosis and spondylotic
Nyunt reported a single case of a missed superior
articular facet of the seventh cervical vertebrae. The patient
had been involved in a motor vehicle accident 7 years prior
to presenting with transient tetraparesis . A case series
of four patients with chip fractures of cervical superior
articular facet and cervical radiculopathy reported excellent
outcomes after posterior fixation .
Whiplash and WAD are a common and costly burden on
the health care system. Associated disabilities and absence
from work create a large impact on economic productivity.
Diagnosis of these injuries can be difficult for the practi-
tioner and frustrating for the patient. The most recent
literature suggests that whiplash injury may occur as a
result of hyperextension of the lower cervical vertebrae in
relation to a relative flexion of the upper cervical vertebrae.
Treatment can be delayed and confused by multiple
social, economic, and psychologic factors. Recent literature
suggests that early mobilization and return to activity may
offer the best chance for recovery. Still, a highly variable
rate of recovery is reported in the literature. The absence of
clear diagnostic and treatment options for this common
medical problem suggest that further research is duly
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