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37 Acupuncture and Chinese Medicine: Equilibrium Disorders
Part V
Conclusive Remarks
383
D.C. Alpini et al. (eds.), Whiplash Injuries,
DOI 10.1007/978-88-470-5486-8_38, © Springer-Verlag Italia 2014
38.1 Introduction
Whiplash-Associated Disorder (WAD) represents a signifi cant public health
problem, resulting in a substantial socioeconomic burden throughout the
industrialised world, wherever costs are documented.
WAD is caused by an acceleration-deceleration mechanism of energy transfer to
the neck, mainly, and the spine, generally. The most common cause of WAD is a
motor vehicle collision (MVC), but sporting accidents or falls can also cause
whiplash.
Under the point view of time course, whiplash may be classifi ed as acute (less
than 2 weeks), subacute (2–12 weeks) or chronic (longer than 12 weeks).
Under the point of view of lesion, WAD has been classifi ed in 1995, by the
Quebec Task Force (QTF) [ 1 ], in four progressive grades. According to the QTF,
‘whiplash is an acceleration deceleration mechanism of energy transfer to the neck,
which…may result in bony or soft tissue injuries (whiplash injury), which in turn
may lead to a variety of clinical manifestations (whiplash-associated disorders,
“WAD”)’ (Table 38.1 ).
D. C. Alpini (*)
ENT-Otoneurology Service, IRCCS “Don Carlo C. Gnocchi” Foundation , Milan , Italy
e-mail: dalpini@dongnocchi.it
G. Brugnoni
Italian Academy of Manual Medicine , Italian Institute for Auxology , Milan , Italy
e-mail: guido.brugnoni@libero.it
A. Cesarani
Department of Clinical Sciences and Community Health , University of Milan ,
Milan , Italy
Audiology Unit , IRCCS “Ca’ Granda” Ospedale Maggiore Policlinico ,
Milan , Italy
e-mail: antonio.cesarani@unimi.it
3 8
Management and Treatment of WAD Patients: Conclusive Remarks
D. C. Alpini , G. Brugnoni , and A. Cesarani
384
Many treatments have been advocated for patients with WAD, and many diagnostic
procedures have been proposed to document lesions or dysfunctions induced by whiplash,
but the majority of therapeutic interventions used in the treatment of WAD had undergone
little to no scientifi c investigation. Due to the paucity of scientifi cally rigorous studies, the
QTF was forced to rely on consensus opinion for the majority of their mandated treatment
recommendations, offering little in the way of evidence-based clinical guidelines.
The conclusive considerations and remarks presented into this chapters on one
hand are based on the main reviews [
2 – 9 ] and the published guidelines [ 9 ] and on the
other hand on the personal experience in the fi eld of diagnosis and treatment of WAD.
Under the point of view of symptoms, main WADs regard pain, especially but
not uniquely neck pain, and unsteadiness. Thus, both management and treatment in
this chapter will be focused on pain and vertigo/unsteadiness.
Management refers to the overall approach to care, or plan, formulated for indi-
vidual patients; treatment refers to the therapeutic modalities utilised as part of the
management approach, including advice and education, exercise, joint mobilisation, pharmacotherapy, etc.
38.2 Management
38.2.1 Acute and Subacute Phases
Neck symptoms, pain and stiffness, are the most common symptoms after a whiplash trauma. Pain often occurs soon, while stiffness can occur later.
Grade Classifi cation
0 No complaint about the neck
No physical signs
1 Neck complaint of pain, stiffness or tenderness only
No physical signs
2
Neck complaint and musculoskeletal signs
Musculoskeletal signs include decreased range of motion and point tenderness
3
Neck complaint and neurological signs
Neurological signs include decreased or absent tendon refl exes, weakness and
sensory defi cit (e.g. hearing loss)
Neck complaint and fracture or dislocation
Table 38.1 Quebec Task Force Classifi cation of Grades of WAD
D.C. Alpini et al.
385
Thus, a comprehensive assessment and physical examination of the patient is
mandatory (see Chaps. 14 and 21 ).
The fi rst aim of the assessment in the acute phase is a correct classifi cation of the
patient in the QTF WAD grade.
Neck symptoms may exist without objective fi ndings during clinical examination
(QTF WAD grade I). Tenderness at palpation over muscle attachments and over
muscles in the cervical spine, the shoulder region and/or the back is common (QTF
WAD grade II). Approximately 50–60 % of patients who present to emergency
rooms have QTF WAD grade II.
It is very important to take in mind that prompt and adequate management of the
acute pain reduces the risk of chronic pain.
History taking is a cornerstone of early management of WAD patients of all
grades.
Personal and circumstances of the injury have to be carefully collected [ 10 ].
Radiological procedure is preferably based on Canadian C-spine rule [ 11 , 12 ]
(Table 38.2 ).
The most important element of initial assessment is the identifi cation of
patients who are at risk of developing serious consequences such as fractures,
dislocations (QTF WAD grade IV) or signifi cant neurological damage (QTF WAD
grade III).
In QTF WAD grade III, specialised imaging techniques (CT scan and/or MRI)
have to be used when nerve root compression or spinal cord injury are
suspected.
QTF WAD grade III may be estimated to be documented in 2–6 % of patients
even if 20 % of patients report neurological symptoms like paraesthesia, sensory
defi cit and weakness in an arm or hand.
Dizziness and unsteadiness are very common, while true vertigo is rare. However,
when a patient complains vertigo that appears on moving the head or in postural
changes, a paroxysmal positioning vertigo (PPV) has to be suspected and adequately
treated (see Chaps. 14 and 23-I ).
Tinnitus is common enough, while hearing loss is rare. However, when a patient
complains of unilateral constant and continuous tinnitus and/or unilateral hypoacusia, a sensorineural sudden hearing loss (SSHL) has to be suspected and adequately
investigated and treated (see Chaps. 11 , 13 , and 17 ).
In QTF WAD grade IV, when imaging confi rms the existence of a fracture, the
patient has to be immediately referred for a specialised management.
38 Management and Treatment of WAD Patients: Conclusive Remarks
386
Pain intensity and disability may be quantifi ed using the Visual Analogue
Scale (VAS) and the Neck Disability Index [ 13 ] (NDI) respectively (Table 38.3 ).
The Canadian C spine rule
For alert (GCS score = 15) and stable trauma patients when cervical spine injury is a concern
1. Any high-risk factor that mandates
radiography?
2. Any low-risk factor that allows safe
assessment of range of motion ?
3. Able to actively rotate neck?
45 degrees left and right
Age ≥ 65 years
or Sitting position in Emergency
Department
or Ambulatory at any time
or Delayed onset neck pain
b
or Absence of midline cervical spine
tenderness
or Dangerous mechanism*
or Paresthesias in extremities
No
No
Unable
Ye s
Ye s
Simple rear-end MVA
a
Able
* Dangerous mechanism
a
Simple rear-end MVA excludes:
b
Delayed
• Fall from elevation
>3 ft/5 stairs
• Axial load to head eg, diving
• Pushed into oncoming traffic
• Hit by bus/large truck
• Rollover
• Hit by high-speed vehicle
• ie, not immediate onset of
neck pain
• MVA high speed (>100km/h),
rollover, ejection
• Bicycle crash
No radiography
Radiography
Table 38.2 Canadian C-Spine Rule
D.C. Alpini et al.
387
Table 38.3 Neck Disability Index
38 Management and Treatment of WAD Patients: Conclusive Remarks
388
Poor prognosis is associated with a high pain score ( VAS > 7 / 10 ) and / or high
disability score ( NDI > 40 / 100 ). The presence of either of these factors should alert
to the potential need for more regular review of treatment or earlier referral to a
specifi c specialist. Identifi cation of poor prognosis patients is mandatory in order to
provide adequate prevention of chronicisation.
Table 38.3 (Continued)
D.C. Alpini et al.
389
Reassessment has to be planned at 7 days, 3 weeks, 6 weeks and 3 months for
acute WAD.
At 3 months resolution has occurred in approximately 50 % of acute cases.
Treatment should have ceased or, if the patient is still improving, self-management
should be promoted.
Patients who still require treatment after 3 months are considered to have chronic WAD.
It could be useful to ‘measure’ the impact of WAD on patient health and life-
style through the ‘Core Whiplash Outcome Measure’ [ 14 ] (Table 38.4 ), a fi ve-item
scale that is brief and user-friendly for clinicians. It measures several constructs of
health including pain, function and well-being. In addition, it measures the days
off work.
Table 38.4 Core Whiplash Outcome Measure
38 Management and Treatment of WAD Patients: Conclusive Remarks
390
Persistent or recurrent vertigo and/or persistent dizziness and unsteadiness have
to be investigated.
Vestibular evoked potentials (see Chap. 17-II ) are specifi c to detect vestibular
lesion causing relapsing positioning vertigo. Posturography allows a precise documentation of stance control disturbances (see Chap. 15 ); Smooth Pursuit Neck
Torsion Test (SPNTT) and Cranio-Corpo-Graphy (CCG) (see Chap. 16 ) allow accu-
rate documentation of cervico-cephalic dynamic control disturbances either as oculomotor (SPNTT) and gait (CCG) disturbances.
Handicap induced by persistent dizziness may be quantifi ed by means of the
Dizziness Handicap Inventory [ 15 , 16 ] (Table 38.5 ).
Instructions: The purpose of this scale is to identify diffi culties that you may be experiencing because of your dizziness or unsteadiness. Please answer ‘yes’, ‘no’ or ‘sometimes’ to
each question. Answer each question as it pertains to your dizziness or unsteadiness problem only.
Does looking up increase your problem?
Because of your problem, do you feel frustrated?
Because of your problem, do you restrict your travel for business or recreation?
Does walking down the aisle of a supermarket increase your problem?
Because of your problem, do you have diffi culty getting into or out of bed?
Does your problem signifi cantly restrict your participation in social activities such as going
out to dinner, going to movies, dancing or parties?
Because of your problem, do you have diffi culties in reading?
Does performing more ambitious activities like sports, dancing and household chores such as
sweeping or putting dishes away increase your problem?
Because of your problem, are you afraid to leave your home without having someone
accompany you?
Because of your problem, have you been embarrassed in front of others?
Do quick movements of your head increase your problem?
Because of your problem, do you avoid heights?
Does turning over in bed increase your problem?
Because of your problem, is it diffi cult for you to do strenuous housework or yardwork?
Because of your problem, are you afraid people may think you are intoxicated?
Because of your problem, is it diffi cult for you to go for a walk by yourself?
Does walking down a sidewalk increase your problem?
Because of your problem, is it diffi cult to concentrate?
Because of your problem, is it diffi cult for you to walk around your house in the dark?
Because of your problem, are you afraid to stay at home alone?
Because of your problem, do you feel handicapped?
Has your problem placed stress on your relationships with members of your family or
friends?
Because of your problem, are you depressed?
Does your problem interfere with your job or household responsibilities?
Does bending over increase your problem?
Table 38.5 Dizziness Handicap Inventory
D.C. Alpini et al.