Whiplash and co: a different slant

Whiplash associated disorder (WAD) is itself associated with a number of other conditions, some of which can manifest in the early stages and some which may not appear until later.

It is a common complaint that at or near the time of the accident, the claimant suffered some form of neurological symptom in one or both arms, usually described as ‘pins and needles’ or suchlike.

Underlying pathology

For those experts who tend to see claimants at
less than three months post-accident, this may
be the only clue that they get to the underlying pathology. If they look no further they risk failing
to correctly diagnose and treat the underlying condition, which will continue indefinitely if left untreated. Claimants will often not report this symptom unless directly asked. To do it properly takes time.

For those who tend to see claimants at a
later stage, that initial period of neurological symptoms may be recorded in the notes or may be volunteered, but again may not be. What will often not be volunteered will be that about three months later similar symptoms returned.

They may only complain of the arm tiring easily. The claimant will often see symptoms appearing some months after the event, and usually involving the forearm or hand (which they did not think was injured) as being unrelated to the injury.

There is a clear link between the injury and the development of these symptoms as well as a simple remedy which will relieve the symptoms in the vast majority of cases. The reason that the early assessments are so important is that the earlier the treatment starts, usually, the less time treatment
is required.

The reason this condition is not generally recognised in orthopaedic practice or even neurosurgical practice (I have come across three reports in 24 years correctly diagnosing the condition, one from a neurosurgeon, one chiropractor and one physiotherapist) is that the more severe forms of the condition are treated
by thoracic surgeons and rarely appear in the
other specialities.

The condition is thoracic outlet syndrome (TOS), in this case caused by muscle imbalance around the shoulder girdle as the upper trapezius and levator scapulae are injured in the accident. The initial strain on the brachial plexus causes the initial symptoms, where present – a mild neuropraxia. What then appears to happen is that, due to the injury, the shoulder girdle gradually drops. At a point about three months post accident this becomes sufficiently severe that the neurological symptoms return.

Brachial plexus

What do they complain of? At first glance, the claimants almost always complain of what appears to be symptoms in a non-neurological pattern. What I propose is that this is not the case – it is the brachial plexus that is being compromised, not individual roots or nerves.

As a result, a wide variety of patterns of symptoms can readily emerge depending on exactly which nerves are worst affected. Vascular symptoms can occur but are very rare, the only significant case I have seen did have a cervical rib that was only remediable with surgery.

In addition, if questioned, female claimants will complain that bra straps and handbags fall from the affected side (but not the other) and that drying their hair is either difficult or impossible. They may have changed hair style because of this.

Claimants may also complain of difficulty driving, reaching high cupboards, carrying even quite light objects and nocturnal discomfort. Many of these complaints will not be volunteered and have to be actively sought or they will be missed.

Other complications can be carpal tunnel syndrome (from a double crush phenomenon) and occasionally ulnar nerve effects.

Specific tests

Examination: observe that the affected shoulder is almost always held significantly lower than the unaffected, often by up to two centimetres – but only when relaxed. The specific tests are the Roos or Adson tests, which will induce the usual symptoms (Roos test – a very similar manoeuvre to holding a hair dryer, which is why symptoms occur then). General examination to rule out other related and non-related conditions is clearly also essential.

Investigations: the temptation is to perform MRI of the cervical spine (certainly prudent if symptoms and/or signs merit) or nerve conduction studies. In TOS these are often normal, and this by no means excludes the diagnosis, if anything it reinforces it by excluding other pathology. Positive tests indicate other pathology or a severe form of TOS such as with cervical rib.

Treatment: there are specific exercises that claimants usually manage to do without the need for physiotherapy, but which they have to adhere to and undertake frequently. The shoulder exercises are best if undertaken about six times per hour of waking, rather than in extended sessions (causes reaction) or less frequently.

Complete relief would be expected in the vast majority of cases within three months of treatment starting, but in more long-standing can take significantly longer. That is why those seeing claimants early should be looking for this condition at the outset.

The condition is not confined to WAD and should also be looked for in any upper limb disorder as it is not infrequent in cases where there has been a shoulder injury or even just a period in a sling, with or without plaster.

Not convinced? A quick web search should do. The Mayo Clinic on their website lists the causes of thoracic outlet syndrome as including ‘physical trauma from a car accident, and repetitive injuries from job- or sports-related activities’. It is the first on the list, and that make sense as it is no doubt the most common.

So while experts are required to show that their expertise is indeed that and that they stick firmly within their field, instructors need to be vigilant that the expert can report on the condition that the claimant requires to be defined and is able to assist in minimising the consequent loss by indicating how best this can be achieved.