Whiplash Associated Disorders
This information is intended to inform you and help you make decisions for your health care needs following the trauma you have received during your automobile collision. The information is based upon scientific research in the field of spinal trauma, collision reconstruction, whiplash injuries, chiropractic care and rehabilitation. We hope that you can make the appropriate actions for your treatment needs based upon this information. If you have any questions about this information or would like to have a consultation with one of our doctors, please feel free to contact us at 503-981-4591.
What is Whiplash?
The term "whiplash" injury was first coined by Harold Crowe in 1928 to define acceleration-deceleration injuries occurring to the cervical spine or neck region. Later modified to an all-encompassing term known as whiplash-associated disorders (WAD). The term WAD is often used synonymously with the term Whiplash however whiplash refers to the mechanism of injury rather than the injury it creates. Whiplash injury is a common trauma of the cervical spine which usually occurs during motor vehicle accidents, especially involving rear-end collisions. The trauma typically results from a sudden biphasic movement of the head and cervical spine (reclination followed by inclination), which may cause an injury of bony, muscular and ligamentous elements. Radiologe 2021
The Physics of Whiplash?
What causes Whiplash Injury?
Based on kinematical studies on the cadaver and volunteers, there are three distinct periods that have the potential to cause injury to the neck. In the first stage, flexural deformation of the neck is observed along with a loss of cervical lordosis; in the second stage, the cervical spine assumes an S-shaped curve as the lower vertebrae begin to extend and gradually cause the upper vertebrae to extend; during the final stage, the entire neck is extended due to the extension moments at both ends. Chin J Traumatol 2009
Nearly one third of all motor vehicle accidents are rear-end collisions. This is the type of accident that is responsible up to 85% whiplash injuries. Turk Neurosurg 2014 If the driver of the front (target) car is relaxed and unaware, the energy of the other car (bullet) is transferred to the front car upon impact and propels it forward. The back of the car seat goes with the car and pushes into the drivers back. However, the drivers head will stay in the same place until the neck pulls it forward with the body (Newton's Law). It is during this time that the soft tissues shear, compress and tear causing the injuries. This is true in other parts of the body as well.
What are Whiplash Associated Disorders?
Whiplash associated disorders (WAD) encompass all injuries associated with the whiplash trauma mechanism. This most commonly includes the head and neck, but can also involve the shoulder, arm, upper back, TMJ and even the lower back. The type of injuries include:
Ligament Tear (Sprain) Muscle Tear (Strain) Nerve Compression Nerve Traction (stretch) Concussion TMJ (jaw dysfunction) Disc Avulsion (tear of disc away from vertebrae) Disc Herniation (include bulge, prolapse, extrusion) Fracture (spine, skull, extremity) Psychological (PTSD, anxiety, depression) Inner Ear Injury Abrasions Contusions Other complications related to trauma.
Pain is not a good indicator of injury severity and getting a thorough examination following any car crash is recommended.
Why everyone in the accident should be examined immediately.
It is important that anyone involved in the crash gets examined within the first week, even if they feel fine. This will allow the physician to determine if injuries were sustained, the severity of any injuries and if treatment is necessary to influence the healing process properly. If an evaluation concludes there are no injuries, then the normal examination becomes invaluable for comparison in the event of a future injury. If you have injuries, the longer you go without proper care, the more difficult it is for you and the doctor to return you to a pre-accident status.
Too often, people involved in low speed collisions (fender benders) do not take the possibility of injury seriously. According to the U.S. Department of Transportation, more than 80% of all car crashes occur at speeds less than 10 MPH. Fatalities involving non-belted occupants of cars have been recorded at as low as 10 MPH. That is about how fast you would drive in a parking lot.
By being examined early, you can begin treatment early. Proper treatment will allow the body to reduce the swelling associated with injury, increase circulation to the injured tissues for quicker healing, and remodel the formation of scar tissues which otherwise can cause long term consequences. Without a proper evaluation initially, many important soft tissue injuries may be missed and allowed to heal incorrectly.
The Evaluation from the Emergency Room May Have Missed Serious Injuries.
When you go to the emergency room or family medical doctor, the evaluation is often brief and the treatment is recommending rest, maybe some medication for pain and swelling and possibly a collar around your neck to prevent your neck from moving. The doctors of the emergency room are looking for things that are life threatening (breathing, bleeding, broken bones). If you appear to be alive with no need for support, they believe you will be fine in a couple of weeks. The truth is: just because your soft tissue injuries are not life threatening, they may 
What are some symptoms of Whiplash (WAD)?
Research done by the Spine Research Institute of San Diego comprised a list of "Common Symptoms Following Whiplash" with the prevalence of their involvement. This is the list provided in their publications:
| Neck Pain | 92% | Impaired Concentration | 26% |
| Headache | 57% | Blurred Vision | 21% |
| Fatigue | 56% | Irritability | 21% |
| Shoulder Pain | 49% | Dysphagia (swallowing) | 16% |
| Anxiety | 44% | Dizziness | 15% |
| Mid Back Pain | 42% | Forgetfulness | 15% |
| Low Back Pain | 39% | Arm Pain | 12% |
| Sleep Disturbance | 39% | Arm Weakness | 6% |
| Arm Tingling | 30% | Tinnitus (ears ring) | 4% |
| Noise Sensitivity | 29% | Jaw Pain | 4+% |
How is Whiplash severity graded?
Classification of Injury Severity
It may be important to grade an injury in order to define reasonable boundaries and devise a successful treatment plan. There are varying sources providing assistance in the grading of whiplash-type injuries. The following grading system will show the differences and similarities between the Quebec Task Force (QTF), Spinal Research Institute of San Diego (Croft), Sterling’s Proposed Classification System, and the Bone and Joint Decade (2000-2010) Task Force on Neck Pain and Association Disorders,. Three of the four are specific for Whiplash Associated Disorders (WAD), while the forth includes whiplash as a possible mechanism for neck injury. Although most of the following grading systems focus on neck injuries, it may be adequate to grade injuries to other regions based upon these systems. (Brain trauma may require a separate grading and treatment approach)
In 1995, the QTF developed the Quebec classification of WAD. The authors proposed this classification system in order to facilitate the evaluation of research and to provide clinicians with useful guidelines for making decisions about therapeutic management. It classified patients with whiplash according to the type and severity of signs and symptoms observed shortly after the injury.
Quebec Task Force Grading System
| Grades of Severity | Clinical Presentations |
| 0 | No neck complaints; No physical signs(s) |
| I | Neck pain, stiffness or tenderness only; No physical sign(s) |
| II | Neck complaint AND musculoskeletal sign(s)* |
| III | Neck complaint AND neurological sign(s)** |
| IV | Neck complaint AND fracture or dislocation |
* Musculoskeletal signs include decreased ROM and point tenderness.
** Neurologic signs include decreased or absent deep tendon reflexes, weakness and sensory deficits.
In 1992, Foreman and Croft published a grading system that preceded and is similar to the popular QTF system above. For most conditions these continue to be useful. Research and experience suggest that WAD trauma can be categorized as to severity based on physical findings rather than on subjective complaints alone. The Croft classification system was also influenced by studies revealing that limitation of motion, ligamentous involvement and neurologic symptoms allow for crude prognostication.
Croft CAD Classification System
| Grades of Severity | Clinical Presentations |
| I | Minimal: No limitation of motion; No ligamentous injury or neurological symptoms. |
| II | Slight: Limitation of motion; No ligamentous injury, no neurological findings* |
| III | Moderate: Limitation of motion; Some ligamentous injury; Neurologic symptoms/findings present |
| IV | Moderate to Severe: Limitation of motion; Ligamentous instability; Neurological symptoms/findings present; Fracture or disc derangement** |
| V | Severe: Requires surgical management |
* Neurologic symptoms/findings include weakness, sensory loss, reflex changes, atrophy.
** Fracture can include minimal end-plate fracture, disc derangement can include non-herniated forms.
Whiplash is a complex multifaceted disorder involving varying degrees of both physical and psychological disturbance. In 2004, a new classification system had been proposed which reflects the complexity of the condition and is inclusive of identified specific impairments. As a consequence of differences in processes between recovered patients and those who develop chronic pain, treatments will vary according to the presence or not of specific physical and psychological impairments.
Sterling Proposed Classification System
| Severity | Physical and psychological impairments present |
| WAD 0 | No complaints about neck pain No physical signs |
| WAD I | No complaints of pain, stiffness or tenderness only No physical signs |
| WAD IIA | Neck complaint Motor impairment •decreased ROM •altered muscle recruitment patterns (CCFT)* Sensory Impairment •local cervical mechanical hyperalgesia |
| WAD IIB | Neck complaint Motor impairment •decreased ROM •altered muscle recruitment patterns (CCFT) Sensory Impairment •local cervical mechanical hyperalgesia Psychological impairment •elevated psychological distress (GHQ, TAMPA)** |
| WAD IIC | Neck complaint Motor impairment •decreased ROM •altered muscle recruitment patterns (CCFT) •increased JPE Sensory Impairment •local cervical mechanical hyperalgesia •generalized sensory hypersensitivity (mechanical, thermal, BPPT)*** •Some may show SNS disturbances Psychological impairment •elevated psychological distress (GHQ, TAMPA) •elevated levels of acute posttraumatic stress (IES)** |
| WAD III | Neck complaint Motor impairment •decreased ROM •altered muscle recruitment patterns (CCFT) •increased JPE Sensory Impairment •local cervical mechanical hyperalgesia •generalized sensory hypersensitivity (mechanical, thermal, BPPT) •Some may show SNS disturbances Neurological signs of conduction loss including: •decrease or absent deep tendon reflexes •muscle weakness •sensory deficits Psychological impairment •elevated psychological distress (GHQ, TAMPA) •elevated levels of acute posttraumatic stress (IES) |
| WAD IV | Fracture or dislocation |
* CCFT refers to the Cranio-Cervical Flexion test for motion dysfunction and muscle recruitment. Other tests can determine this finding also.
** GHQ, Tampa, and IES are questionnaires for psychological stress, fear of movement due to injury and impact of events scales.
*** BPPT refers to the Brachial Plexus Provocation Test used to measure hypersensitivity.
In 2008, another task force was developed to provide a much broader scope, encompassing most of neck pain, including but not limited to WAD. This system focuses on ADL involvement and provides some guidance to treatment requirements. There are similarities between this classification system and the QTF and Croft criteria above.
| Grade I | No signs or symptoms suggestive of major pathology and no or minor interference with activities of daily living (ADL); Will likely respond to minimal intervention such as reassurance and pain control; Does not require intensive investigation or ongoing treatment. |
| Grade II | No signs or symptoms suggestive of major pathology, but major interference with ADL; Requires pain relief and early activation/intervention aimed at preventing long-term disability. |
| Grade III | No signs or symptoms suggestive of major pathology, but presence of neurological signs such as decreased DTR, weakness, and/or sensory deficits; Might require investigation and, occasional more invasive treatments. |
| Grade IV | Signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or systemic disease; Requires prompt investigation and treatment. |
Are there treatment guidelines for Whiplash?
The durations presented in these published guidelines are not intended to encourage treatment beyond that necessary for symptom relief and/or restoration of normal function. Nor are they intended to serve as instruments for the premature termination of necessary care. They are provided to help clinicians gauge severity of injuries and therapeutic responses to care. They should not be interpreted as prescription treatment protocols. The chief factor determining both treatment frequency and duration is the individual patient’s response to treatment documented by evidence-based outcomes management.
Injury severity may be an important marker in the determination of formulating a treatment plan. This allows the practitioner the ability to define reasonable boundaries for treatment. Other resources are available that offer durations of care for WAD type injuries. The diversity of the available data can vary greatly making a prognostic value difficult. Of the resources for severity classifications shown above, only Croft’s offer a suggested treatment schedule for each level of severity.
The durations and number of visits published by Croft are expressed as approximations only and based on statistical observations. It is noted that patients not at high risk for poor outcome should not require treatment approaching the published maxima per severity grade, and may respond to care surprisingly fast. Conversely, patients with risk factors associated with poor outcomes may require treatment that approaches or even exceeds the published maxima. It is important to stress that guidelines are merely guides to care, not prescriptions for treatment schedules. The patient and their response to care should always be the key indicator for treatment need.
Croft’s Treatment Guidelines for WAD
| Grade | Daily | 3x/wk | 2x/wk | 1x/wk | 1x/mo | TD | TN |
| I | 1 wk | 1-2 wk | 2-3 wk | <4 wk | ___* | <10 wk | <21 visit |
| II | 1 wk | <4 wk | <4 wk | <4wk | <4 mo | <29 wk | <33 visit |
| III | 1-2 wk | <10 wk | <10 wk | <10 wk | <6 mo | <56 wk | <76 visit |
| IV | 2-3 wk | <16 wk | 12< wk | <20 wk | ** | ** | ** |
| V | Surgical stabilization necessary: Chiropractic care is post-surgical |
TD= Treatment duration TN= Treatment number * possible follow-up at one month ** may require permanent monthly or prn care
This source indicates daily treatment in the early stages: (a) may limit scar formation, (b) allows for daily communication on ADL’s, work demands and response to treatment, (c) allows better monitoring of any neurologic injuries, (d) allows monitoring of patient compliance to home instructions, and (e) because of neuroplasticity it is important to manage and minimize pain early and often. In most cases, grades I-III will require only 1 week of daily treatment. There is little advantage in providing daily treatment on patients who begin care in the sub-acute or chronic stages.
The end care for each of the above grades of injury shows decreased treatment frequency. (ex: Grade III allows up to 56 weeks of care, but 6 months are 1x/mo visits). The rate of decreased treatment frequency should be based upon the individual patient’s improvements and ongoing treatment needs as indicated by regularly performed re-evaluations. This may allow resolution sooner than this guideline indicates.
Should I see a Chiropractor to treat Whiplash?
Although medical physicians have a definite place in the health care of this country, their education may not support them as the expert or specialist in the field of automobile accidents. On the other hand, Doctors of Chiropractic have the most extensive background and education on conditions involving the neuromusculoskeletal (NMS) system. The term neuromusculoskeletal basically refers to your nervous system, your muscular system, and your skeletal system (joints). These are the primary sources of injury involved in automobile collisions, as well as most other traumas. The following is a comparison from the chiropractic college and medical college in Oregon of class-room hours that educate areas of common injuries:
Class Chiropractic Hours Medical Hours
Anatomy 288 190
Neuroanatomy 96 84
Histology (soft tissues) 44 84
NMS Diagnosis 276 158
X-ray 376 24
Total Class Room Hours 3,768 2,465
In addition, the doctors of Northwood Health Center continually study the specific mechanisms for injuries in automobile collisions, the most beneficial treatment protocols necessary to return you to a pre-accident status, the long term effects associated with these injuries and many other post-graduate classes designed to assist us in helping you with your care.
Chiropractic Adjustments (Manipulative Therapy) not only assists in pain relief, it stimulates joints to retrain nervous input, remodel injured soft tissues, restore function and correct structural abnormalities. It is the only therapy that addresses the para-physiological joint mobility (beyond passive motion, but before damage). This is what allows the soft tissues to be remodeled and the movement neurology to be retrained.
Pain is a Poor Indicator of Injury Severity.
Most people involved in an automobile collision experiences pain in one way or another. Sometimes it is severe and prevents you from doing anything. But many times the pain is mild and does not necessarily affect your lifestyle. It is in this case that people place themselves in danger of causing potential long term problems as a result of missed injuries.
Some studies found that symptoms from accident injuries can be delayed days, even months down the road. Headaches, neck pain, arm pain, etc. can all be minimal at the onset of injury. Only to be exacerbated with the increased stress of occupational duties, activities of daily living, and/or the secondary affects of the healing process. During the healing process, your torn tissues will heal with a scar. This scar will cause the damaged tissues to become less flexible, weaker, and more sensitive. This increase in sensitivity may cause the increase in pain months later.
When you do receive care for your injuries, even immediately, the pain is not the measure of recovery. Although pain may be the primary goal initially, the functions of the body consisting of motion, strength, endurance and ability to withstand stress are actually more important and need to be addressed. When your pain goes away, many times your functions are still significantly limited.
Pain is not a reason to start or stop treatment. Pain is merely an effect of something damaged or incorrect in your body. We utilize and share the findings of your evaluations to determine your treatment needs and modifications, initially and throughout your treatment program until you are either back to a pre-crash status or have reached a stationary status.
Aspirin and Drugs Do NOT Heal Your Injuries.
Although there are times when symptoms and pain are so severe that it takes medication to allow you to maintain your sanity, do not mistake their role as pain relievers with an ability to heal you. In fact, many times the numbing affect medication has on your body will mask the presence of more serious injuries.
The longer you wait to have the cause of your pain evaluated, the more serious it will be when it is found. In addition, the longer you wait, the more difficult it will be to effectively treat your injuries which are causing your symptoms. Sometimes we see patients that have waited too long, and there is nothing left that we can do for them. There is nothing left for anyone to do but provide them a lifetime of taking drugs to mask the pain that is inevitable in their future. However, all of this can be avoided by getting an early examination after your accident and following the treatment plan scheduled by your doctors.
Does my auto insurance cover my whiplash injuries?
Oregon automobile coverage includes Personal Injury Protection (PIP) which allows anyone injured in a car crash to receive reasonable and necessary treatment. Under your auto insurance, you do not need a referral to see a chiropractor. Occasionally an insurance company personnel may inform you that you can not see a chiropractor for your accident without a referral. This is not true. The current laws in the State of Oregon allow the freedom for you to choose your health care provider under the Personal Injury Protection act.
Under your auto insurance, if you are involved in an accident, your policy states they must pay for all services which are considered reasonable and necessary within two years of the accident. We will not recommend any treatment that we do not feel is reasonable, necessary and directly related to your car crash. Our services are supported by research studies and text books on automobile accident injuries and can be proven to be reasonable and necessary which allow them to be covered by your policy.
Chiropractic Treatment is Very Effective For Post-Traumatic Injuries.
The doctors of Northwood Health Center will evaluate your injuries very specifically with appropriate examinations and x-rays if necessary. After thoroughly studying your findings, we will go over everything with you regarding your injuries and what we feel is the best course of treatment for you.
Studies recommend an active approach to your health care needs even after trauma. Our treatment methods address the specific needs of your damaged tissues by assisting their healing process. This allows the overall health of the tissues to be more functional, similar to tissues that were never damaged.
And by re-evaluating your injuries regularly, 
If you have been involved in a car crash, it is important to get an evaluation done by a trained chiropractor who understands car crash mechanisms and injuries.