Whiplash Associated Disorder (WAD)
Whiplash injury may be caused by a sudden impact where the the energy produced by the acceleration-deceleration of the head is transferred to the neck (1). As a result, the neck is moved beyond its usual range of motion which can sprain the soft tissues of the neck including muscles, ligaments and tendons (2), or cause injury to the bone (3). Most commonly causing pain and discomfort in the neck and shoulder, the back may also be affected (4). The resulting pain and other associated clinical manifestations are collectively grouped under the term whiplash associated disorders (5).
Whiplash injuries are commonly caused by:
- motor vehicle accidents
- a sudden blow to the head from contact sports such as rugby or boxing
- being hit on the head by a heavy object
- a slip or fall where the head is jolted or jarred (6)
Pain and discomfort often start 6 to 12 hours after the injury with swelling, bruising, and increased pain occurring over the following days (7). While symptoms of whiplash often greatly improve or resolve within one to fours weeks, some people experience pain and neck stiffness for months after the initial injury (8).
Quebec Task Force Classification of Grades of WAD (9)
Chronic Mechanical Neck Pain
Chronic mechanical neck pain may be caused by a dysfunction of a variety of structures within the neck and is associated with nonspecific degenerative changes such as cervical spondylosis, also known as osteoarthritis (10). It is the most common cause of chronic mechanical neck pain, and as there is no cure for cervical spondylosis, treatment is usually focused on management of symptoms (11). It affects most people over the age of 65 years and is degenerative and progressive in nature (12). Symptoms consist of episodic pain, stiffness, or both, and if left untreated, frequency and severity can worsen (13).
Tension Neck Syndrome (TNS)
TNS is defined as myofascial pain occurring the neck and shoulder regions and symptoms include pain, tenderness, stiffness and fatigue of the neck and shoulder muscles, headaches radiating from the neck, without a history herniated cervical disks, neck injury or degenerative processes (14). Chronic neck pain (lasting longer than 3 months) is the most frequently occurring symptom of TNS (15). TNS is commonly observed in women, most frequently computer users such as students, office workers and other professionals (16).
Myofascial Trigger Points
One of the most common causes of musculoskeletal pain, myofascial trigger points (MTrP) are hypersensitive palpable nodules that present in a taut band of skeletal muscle fibre (17). Associated symptoms include referred pain, restricted range of motion and motor dysfunction (18).
Studies have shown that acupuncture can provide pain relief, improve range of motion and speed up recovery time. Neck pain is one of the conditions listed in the Acupuncture Evidence Project for which there is moderate evidence supporting the use of acupuncture as an effective treatment (19). Electroacupuncture is often used in the treatment of injuries as it has been found to release powerful pain relieving substances within the body (references and article here).
What to expect
Following the first treatment it is possible to feel a either marked improvement, no change, or a temporary exacerbation of the pain. While an improvement in range of motion and reduction of pain is a positive sign, it does not necessarily indicate instantaneous recovery. It may however indicate that the body is responding well and that a follow up treatment soon after is advisable to maintain this momentum. A common mistake made by patients is believing they are fully recovered after just one treatment and going back to normal duties which can further set back recovery time or even worsen the injury.
Similarly, if the state of the condition does not change or temporarily worsens, this does not necessarily indicate a negative response. Depending on how the long the injury has been present may effect the body’s response time to treatment and it may take more than one session to gain noticeable relief. On occasion the body can react to treatment in seemingly adverse ways such as increased pain, but this is usually very short term and commonly followed by an improvement of the condition.
Course of treatments
As is the case with most musculoskeletal conditions, 2 weekly treatments for at least several weeks are generally advised in the initial stages to gain momentum and see effective results before spacing the treatments out to once per week/ per fortnight/ per month. While it is not uncommon for positive results to be seen immediately after a single treatment or in the following hours or days, the effects of acupuncture can also be cumulative so a treatment plan consisting of multiple treatments may be advised in order to see more effective results.
There are a wide range of factors that determine the amount of time and treatments required for any patient’s condition. Duration and severity of the condition play a big part in determining the length and extent of your treatment plan. If the condition is less severe and has only been present for a short amount of time, then a greater response with faster recovery time is more likely. With chronic and more severe conditions, weeks or perhaps even months of consistent, yet less frequent treatments may be required in order to restore full function or for the condition to be manageable.
Other factors that play a role in response to treatment are age and and general health of the patient. What you do after your treatment also has an effect on how well you respond. The more you can do post-treatment to complement the acupuncture, the better your results will be. This may include performing assigned stretches, or using prescribed herbs or liniment to support the acupuncture, or not exerting yourself in the time following the session which may undo the treatment.
Acupuncture research for neck pain – click to expand
40 patients with WAD symptoms were randomised into an acupuncture treatment group or waiting-list group. The treatment group received acupuncture 3 times per week for 2 weeks (20), while the waiting-list group received no acupuncture (21). Both groups maintained their usual care, including physiotherapy, exercise and sufficient rest for 2 weeks, yet were instructed to stop taking drugs such as analgesics and anti-inflammatories for the duration of the trial period (22).
This was a feasibility pilot study to determine the effectiveness of acupuncture in patients with WAD for further studies (23). Consequently the short treatment period may be insufficient for patient recovery and proper assessment of the results of acupuncture treatment (24). Despite this, results of this study showed that acupuncture significantly decreased pain intensity (25), and improved cervical range of motion compared to the waiting-list group (26).
39 patients with chronic WAD participated in the study (27). Inclusion criteria consisted of a diagnosis of chronic WAD grades 1 – 3; chronic neck pain and WAD persisting for at least 3 months; and aged between 18 – 65 years (28). Treatment consisted of one session with acupuncture and one session of guided imagery relaxation consisting of listening to an audio CD (29). Group 1 (20 patients) received acupuncture followed by relaxation; group 2 (19 patients) received relaxation followed by acupuncture (30). Patients were assessed immediately before and after treatments to determine (i) activation of endogenous analgesia, and (ii) resulting pain relief and reduction of disability (31).
For the acupuncture treatments, post-treatment assessments revealed immediate improvements in neck disability, neck pain, headache, sweating and hypersensitivity to bright light, whereas the relaxation session only reduced levels of sweating (32). Local pressure pain sensitivity improved in response to acupuncture in the neck region, as well as other painful areas unrelated to the neck that were treated, suggests that acupuncture may activate endogenous analgesia in patients with chronic WAD (33).
46 patients (37 females; 9 males, ages 20 – 60 years) with diagnosis of tension neck syndrome (TNS) were randomly allocated to 3 groups (34). Group 1 received a course of physiotherapy combined with acupuncture, group 2 received acupuncture alone, and group 3 received physiotherapy alone (35). The course of treatments consisted of one to two sessions per week for ten weeks, and a follow up of six months after the last treatment. No medication or other treatment was given to the group during the intervention period (36).
Results of this trial indicated that physiotherapy combined with acupuncture significantly reduced pain intensity and muscle tension, decreased disability, and also improved isometric neck muscle strength in patients with TNS (37). The trial found that both physiotherapy and acupuncture produced pain relief and muscle relaxation effects when applied individually or simultaneously (38). From the data it was observed that patients who received the combination of physiotherapy and acupuncture had better pain control than those received physiotherapy alone (39).
19 subjects (11 female, 8 male) (40) were randomised into 3 groups and received either real acupuncture, real acupuncture plus stretching, or placebo laser acupuncture where laser needles are fixed to the skin but the device remains off (41). Myofascial trigger points were confirmed by a physician by the presence of a tender spot in a taut band; referred pain pattern on palpation; patient pain recognition on palpation; and positive jump sign (42).
Five minutes after treatment, both real acupuncture and real acupuncture plus stretching reduced pressure pain: acupuncture increased mechanical pain threshold by 5% while acupuncture combined with stretching exercises led to an increase of 11% (43). Range of motion was significantly increased by the application of acupuncture plus stretching compared to placebo (44).
- Tough, E, White, A, Richards, S & Campbell, J 2010, ‘Myofascial trigger point needling for whiplash associated pain e A feasibility study’ Manual Therapy, Vol. 15, pp. 529 – 535, viewed 22 June, www.sciencedirect.com, p. 525
- Healthdirect 2017, ‘Whiplash’, Healthdirect website, viewed 2 August 2017, https://www.healthdirect.gov.au/whiplash
- Tough et al. 2010, loc.cit.
- Healthdirect 2017, loc.cit.
- Tough et al. 2010, loc.cit.
- Healthdirect 2017, loc.cit.
- NSW Government 2014, Guidelines for the management of acute whiplash associated disorders for health professionals, Motor Accidents Authority, viewed 2 August 2017, http://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/The%20APA/StatePAGES/TAS/TAS_Final-Guidelines-for-the-management-of-a~d-WAD-disorders-for-health-professionals-3rd-edition-2014-MAA32-0914-28-11-14a.pdf, p. 4
- White, P, Lewith, G, Prescott, P & Conway, J 2004, ‘Acupuncture versus Placebo for the Treatment of Chronic Mechanical Neck Pain’, Annals of Internal Medicine, Vol. 141, No 12, pp. 911 – 919, viewed 22 June, www.proquest.com, p. 911
- Fran, D, Senna-Fernandes, V, Cortez, C, Jackson, J, Bernardo-Filho,M & Guimaraes, M 2008, ‘Tension neck syndrome treated by acupuncture combined with physiotherapy: A comparative clinical trial (pilot study)’, Complementary Therapies in Medicine, No. 16, pp. 268 – 277, viewed 22 June 2017, www.proquest.com, p. 269
- Ibid, p. 273
- Wilke, J, Vogt, L, Niederer, D, Hübscher, Rothmayr, J, Ivkovic, Rickert, M & Banzer, W, 2014, ‘Short-term effects of acupuncture and stretching on myofascial trigger point pain of the neck: A blinded, placebo-controlled RCT’, Complementary Therapies in Medicine, Vol. 22, pp. 835 – 841, viewed 22 June, www.proquest.com, p. 836
- McDonald, J & Janz, S 2017, ‘The Acupuncture Evidence Project: Plain English Summary’, AACMA Website, viewed 21 April 2017, http://acupuncture.org.au/OURSERVICES/Publications/AcupunctureEvidenceProject.aspx, p. 2
- Kwak, H, Kim, J, Park, J, Lee, S, Yu, H, Lee, J, Cho, K, Katai, S, Tsukayama, H, Kimura, T & Choi, D 2012, ‘Acupuncture for Whiplash-associated disorder: A randomized, waiting-list controlled, pilot trial’, European Journal of Integrative Medicine’, Vol. 4, pp. 151 – 158, viewed 22 June, www.sciencedirect.com, p. 151
- Ibid, p. 153
- Ibid, p. 157
- Ibid, p. 156
- Ibid, p. 157
- Ibid, p. 154
- Tobbackx, Y, Meeus, M Wauters, L, De Vilder, P, Roose, J, Verhaeghe, T & Nijs, J 2013, ‘Does acupuncture activate endogenous analgesia in chronic whiplash-associated disorders? A randomized crossover trial’, European Journal of Pain, Vol. 17, pp. 279 – 289, viewed 22 June 2017, www.ebsco.com, p. 281
- Ibid, p. 282
- Ibid, p. 285
- Ibid, p. 284
- Ibid, p. 286
- Ibid, p. 287
- Fran et al. 2007, op.cit. p. 269
- Ibid, p. 270
- Ibid, p. 275
- Ibid, p. 274
- Wilke et al. 2014, op.cit. p. 838
- Ibid, p. 836
- Ibid, p. 837
- Ibid, p. 838
- Ibid, p. 835
Featured image – Tortora, G & Derrckson, B 2012, Principles of Anatomy and Physiology 13th ed, Wiley, USA, p. 389
Image 1 – http://www.webmd.com/pain-management/ss/slideshow-acupuncture-overview