Whiplash assessment tools

The Guidelines for the management of acute whiplash associated disorders recommend the use of the following assessment tools and outcome measures for the best possible management of adults with a whiplash injury.

Overview

The guidelines recommend the use of standardised assessment tools to assess and diagnose whiplash injury, as well as the outcome measures to monitor progress and direct treatment. Outcome measures are the best way to monitor progress with recovery and to identify people at risk of poor recovery.

This flowchart provides a structure for assessing and treating people with whiplash during the first 12 weeks following an injury. It contains information about when to use each of the tools, how to interpret the scores and what action is recommended in the Guidelines.

Is an X-ray required?

At the initial visit, practitioners should use the Canadian C-Spine Rule to determine whether an X-ray of the cervical spine is required for diagnosis of fracture or dislocation. Effective use of this tool will avoid exposing the injured person to unnecessary exposure to X-rays.

The Canadian C-Spine Rule is for alert and stable trauma patients when cervical spine injury is a concern.

Recommended action

Refer for radiography if indicated by the outcome of the Canadian C-Spine Rule (A3, page 16 guidelines).

Classifying injury severity

The Guidelines recommend classifying the whiplash injury to indicate severity. The Quebec Task Force Classification of Grades of Whiplash Associated Disorders is shown in the table below (A4, page 18 guidelines). Symptoms and disorders that can manifest in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia and temporomandibular joint pain.

GradeClassification
0No complaint about the neck.
No physical sign(s).
IComplaint of neck pain, stiffness or tenderness only.
No physical sign(s).
IINeck complaint AND musculoskeletal sign(s).
Musculoskeletal signs include decreased range of movement and point tenderness.
IIINeck complaint AND neurological sign(s).
Neurological signs include decreased or absent tendon reflexes, weakness and sensory deficits.
IVNeck complaint AND fracture or dislocation.

Source
Spitzer, W.O., Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: Redefining ‘whiplash’ and its management. Spine, 1995. 20: p. 1-73.

Assessing pain (VAS)

The Visual Analogue Scale (VAS) measures pain intensity. The VAS consists of a 10cm line, with two end points representing 0 (‘no pain’) and 10 (‘pain as bad as it could possibly be’).

Ask the patient to rate their current level of pain by placing a mark on the line. Use a ruler to measure the distance in centimetres from the ‘no pain marker’ (or zero) to the current pain mark. This provides a pain intensity score out of 10; for example, 6 out of 10 (or 6/10).

Recommended action

Provide more concerted treatment or consider earlier referral to a clinician with expertise in the management of whiplash for patients with high pain intensity – e.g. pain greater than 5 out of 10 on the VAS (P1, page 19 guidelines).

Source
Scott, J. and E. Huskisson, Graphic representation of pain. Pain, 1976. 2(2): p. 175-184.

Assessing disability (NDI)

The Neck Disability Index (NDI) is designed to measure neck-specific disability and is based on the Oswestry Disability Questionnaire.

The questionnaire has 10 items concerning pain and activities of daily living including personal care, lifting, reading, headaches, concentration, work status, driving, sleeping and recreation. Each item is scored out of 5 (with the ‘no disability’ response given a score of 0) giving a total score for the questionnaire out of 50. Higher scores represent greater disability. The result can be expressed as a percentage or as raw scores (out of 50).

In the guidelines, use of the raw score is recommended. Using the neck disability index form, the scores are automatically calculated.

Recommended action

Provide more concerted treatment or consider earlier referral to a clinician with expertise in the management of whiplash for patients with high disability related to neck pain – e.g. NDI score greater than 15/50 (P1, page 19 guidelines).

Sources
Vernon, H. and S. Mior, The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther, 1991. 14(7): p. 409-15.
Fairbank, J., et al., The Oswestry low back pain disability questionnaire. Physiotherapy, 1980. 66(8): p. 271-273.

Expectations of recovery

Positive expectations of recovery are associated with good recovery, while negative expectations of recovery are associated with poorer recovery.

At the initial assessment, assess the patient's expectations of recovery by asking them: ‘Do you think you are going to get better soon?’

Examples of positive responses:

Examples of negative responses:

Recommended action

If the patient has a negative response, the patient should be monitored. If improvement/recovery is not occurring by three to six weeks post injury, consider referral to a clinician with expertise in the management of whiplash (P3, page 20 guidelines).

Source
Ferrari, R. and D. Louw, Correlation between expectations of recovery and injury severity perception in whiplash-associated disorders.Journal of Zhejiang University SCIENCE B, 2011. 12(8): p. 683-686.

Assessing psychological status (IES)

The Impact of Event Scale (IES) is a measure of post traumatic stress symptoms related to a specific event.

This questionnaire contains 15 comments made by people after stressful life events. The patient is to complete the questionnaire by indicating how frequently these comments have been true for them in the past seven days.

Using this form, the scores are automatically calculated. A higher score indicates a higher level of stress.

Recommended action

A total score of 25 or more, at three to six weeks after injury, is in the ‘moderate’ range (P4, page 20 guidelines). Consider referral to a psychologist for:

  • adjustment difficulties
  • management of pain and/or
  • posttraumatic stress management.

Source
Horowitz, M., N. Wilner, and W. Alvarez, Impact of Event Scale: a measure of subjective stress. Psychosom Med, 1979. 41(3): p. 209-18.