Subgrouping patients with chronic whiplash-associated disorders; a way of improving the effect of our therapy?   January 30th, 2019

​Whiplash associated disorders (WAD) is among the most common accident-related disorders (about 300 per 10.000 inhabitants in western countries) that have extensive consequences for patients, healthcare services and insurance companies (Tournier et al. 2016). The mechanisms underlying recovery or persistence of WAD remain uncertain and existing evidence on prognostic factors made it clear that physical, physiological and social factors can all play a role (Walton & Elliot. 2017).

Different factors as post-injury pain and disability, whiplash grades, cold hyperalgesia, post-injury anxiety, catastrophizing, compensation and legal factors, and early healthcare use are all associated with the persistence of pain and disability in people suffering from WAD (Sarrami et al. 2017). Furthermore, evidence suggest that chronic WAD  (>3 months) is associated with disturbances in motor function, the presence of generalized sensory hypersensitivity (likely as a result of sensitized nociceptive pathways within the central nervous system), and psychological distress (Sterling et al, 2004). Readers interested in the presence of central sensitization in people with WAD are advised to read the earlier blogof pain in motion colleague Castaldo (October 2018), where he wrote about this relationship. Overall, it is safe to say that whiplash is a highly complex syndrome in which multiple factors can all play a more or less dominant role. 

Despite the fact that there have been advances in the management of whiplash, the number of people who fully recover following a whiplash injury has not increased and, subsequently, the rate of transition to chronic neck pain has not lessened (Jull. 2016). Consequently, it is suggested that the recovery process and the management of chronic WAD can be optimized by defining homogenous subgroups within this population. Classifying people with chronic WAD into more homogenous subgroups can lead to tailoring interventions and to control for subgroups differences when evaluating treatment outcome, butwill also aid in the exploration of the factors contributing to ongoing disability in this population (Pedler & Sterling. 2013).

In the post two decades different authors described different types of classifications and characteristics that can be used to distinguish patients with whiplash. These models have been criticised (some more than others) for not providing a complete picture of the complexity of whiplash or not providing a classification that is easy to use in the daily practice.                                                                                                                From that information, I am currently conducting research within my PhD project, aimed at collecting the data needed to produce subgroups within the population of chronic whiplash that are workable in the daily practice. In the coming period you can expect multiple articles reporting about the outcomes of my research. I would therefore invite you to take note of this in due time. For now we can conclude that the effect of our therapy for chronic whiplash is not optimal and the aspect creating subgroups might be helpful.

Erwin Hendriks, Master of Science in manual therapy and sports physiotherapy. Part of the Pain in motion Research Group. Currently working as a physiotherapist at the Erasmus medical centre in Rotterdam (Netherlands) and the Rehabilition Centre Drechtsteden in Dordrecht (Netherlands). Furthermore giving lecture at the Hogeschool Rotterdam and Breederode Hogeschool.

Pain in Motion, 2018

References and further reading:

Jull, G (2016). Whiplash continues its challenge. J Orthop Sports Phys Ther, 46(10), 815-817

Pedler A, Sterling M. Patients with chronic whiplash can be subgrouped on the basis of symptoms of sensory hypersensitivity and posttraumatic stress. Pain 2013; 154: 1640-8.

Sarrami P, Armstrong E, Naylor JM & Harris IA (2017). Factors predicting outcome in whiplash injury: a systematic meta-review of prognostic factors. J Orthop Traumatol, 18(1), 9-16

Sterling M (2004). A proposed new classification system for whiplash associated disorders – implications for assessment and management. Man Ther, 9(2), 60-70

Tournier C, Hours M, Charnay P, Chossegros L, Tardy H (2016). Five years after the accident, whiplash casualties still have poorer quality of life in the physical domain than other mildly injured casualties: analysis of the ESPARR cohort. BMC Public Health, 16, 13

Walton, DM & Elliot JM (2017). An integrated model of chronic whiplash-associated disorder. J Orthop Sports Phys Ther, 47(7), 462-471