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rest; sleep interruption of 2-3 times per
night and interscapular pain of 4-5/10.
The patient considered the nature of 
the disorder as impairing to his work as
a police officer. Present history included
the onset of symptoms shortly after
being rear-ended. He described the
impact as unexpected and strong, forc-
ing the back of his head into the head
support.  Past history was unremark-
able with no previous injuries, neck or
back pain. Special Questions revealed
good general health and no neurological
signs.  The patient denied sub-occipital
pain, headaches, nausea, vomiting, dizzi-
ness, diplopia, dysarthria, dysphagia or
drop attacks. Cervical spine x-rays taken
at the emergency room were unremark-
able and he was discharged with a pre-
scription for pain medicine. Since pain
was increased to 6/10 by standing or sit-
ting for periods longer than 15-minutes
and subsiding to its prior level after only
a few minutes of resting, the injury 
was considered to be none irritable.  The
total score of the patient specific func-
tional scale (PSFS) was 3.3/10.

In the absence of contraindications, a
physical examination focusing primarily
on the cervical spine was planned. 
The physiotherapy clinical practice guide-
line for WAD advises that the physical
examination should include general

2 SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3

Physiotherapy in a Whiplash Injury:
A Case Report

C a s e

R e p o r t

INTRODUCTION
The Quebec Task Force on Whiplash
Associated Disorders (WAD) defines
whiplash as an acceleration-deceleration
mechanism of energy transfer to the
neck. It may result from a rear-end 
or side-impact motor vehicle accident
(MVA), or other mishaps. After a 
MVA, 62% of vehicle occupants develop
neck pain. The most common symptoms
of whiplash injury include neck pain,
headache, stiffness, shoulder/arm pain,
muscle fatigue, paraesthesia, dysphagia,
visual and auditory disturbances, 
dizziness, poor concentration and sleep
disturbances. The Quebec Severity
Classi fication of WAD is based on clinical
presentation and graded 0-IV. WAD II
classification is defined as a whiplash
injury with neck symptoms and muscu-
loskeletal sign(s). Inconsistencies in the
literature exist regarding the prognosis
of whiplash injury, ranging from 
favorable to non-favorable. Only 22% 
of whiplash patients resume usual acti -
vities within a month after the incident
and up to 60% report pain and disability

at 6 months. Chronic whiplash disorders
(symptoms or disabilities persisting for
more than six months) have significant
long-term economic implications.   In
patients with normal recovery a gradual
improvement in physical and mental
function, activities of daily living (ADL)
and participation in work are expected.
Contributing factors associated with
delayed recovery include previous injury,
headache, neck pain after the accident,
employment status, type of collision,
compensation, clinical findings, cultural
differences, coping strategies and phy -
sical as well as psychosocial well-being. 

METHODS

THE SUBJECTIVE EVALUATION
Background: The patient was a 29-year
old male complaining of neck pain 
and tightness as well as low back pain
following a MVA.  He was referred to
physiotherapy two weeks after the acci-
dent. The patient described his main
complaint as an “ache and tightness” in
his neck (left worse than right), extending
towards his shoulder blades. Behavior
of symptoms included neck pain of 
4-5/10 on a Numeric Pain Rating Scale
(NPRS), aggravated by movement, 
prolonged standing or sitting; fatigue
when “holding his head up”, relieved with

Correspondence to:
Corné van Eck
Cell: 076 137 0084
Email: fcvaneck@vodamail.co.za

A BST R A CT: 
Study Design: Case Report
Objectives: To describe physiotherapy intervention in an individual with a
suspected whiplash injury.
Back ground: The patient was a 29-year old male with complaints of neck
pain and tightness following a motor vehicle accident. 
M ethods and M easures: The focus of the case study is physiotherapy
assessment and intervention in a stage II whiplash injury. 
R esults: Following intervention, positive changes occurred in outcome measures such as pain, work status and activi-
ties of daily living. 
Conclusion: Physiotherapy intervention is successful in addressing whiplash associated disorders.

KEY W ORDS: PHY SIOTHERA PY, W HIPLA SH INJURY, MOBILIZATION, THERA PEUTIC EX ERCISE, NEURA L
TISSUE MOBILIZATION, PATIENT EDUCATION.

Van Eck C,
PT, DPT, OCS, COMT, FAAOMPT
B Physiotherapy (Cum Laude)1

1
University of Pretoria, South Africa.



SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3          3

observation, regional examination, range
of motion, quality of movement, symp-
tom provocation, muscle strength and
cervical proprioception. 

THE PHYSICAL EXAMINATION
Observation: The patient lacked spon-
taneous neck movement and appeared to
be in discomfort. Postural assessment
revealed decreased cervical lordosis,
upper cervical extension and a kyphotic
cervical-thoracic junction. Neurological
testing was not indicated at this 
time. Active physiological movement:
A CROM Instrument (product of
Performance Attainment Association,
958 Lydia Drive, Roseville, Minnesota,
5513) was used to measure active cer -
vical range of motion. The patient was
instructed to report any symptoms and
to stop moving at the first onset of pain
(P1) or stiffness (R1). Active movement
was restricted in all directions. The
patient complained of muscle pulling on
both sides of his neck during extension,
left side bend (LSB) and left rotation
(LR). Differentiation between the upper
and lower cervical spine revealed the
latter to be more involved. Alar and
transverse ligament stability testing
and provocation testing of the odontoid
process were unremarkable. Palpation
revealed a slight increase in skin tem -
pe rature as well as tenderness of the
musculature in the cervico-thoracic
region and over facet capsules of C3/4-
C5/6 bilaterally. Passive physiological
inter-vertebral movement (PPIVM)
was performed to further isolate the
source of the disorder and to identify
possible treatment techniques. The
patient was instructed to communicate
reproduction of symptoms while the
therapist was palpating for a joint sign.
Segmental extension at C3/4 - C5/6 (L)
was limited and segmental side bend
(SB) findings included painful levels at
C3/4 - C5/6 bilaterally. Manual examina-
tion of inter-segmental mobility is 
widely used and accurate in identifying
symptomatic levels. Relevant findings
of passive inter-vertebral accessory
movements (PAIVM) are described 
in table 2. Cervical muscle testing of
the deep neck flexors (DNF) was tested
with an inflatable biofeedback cuff,
(Chattanooga Group, Chattanooga, TN)
holding a 4-mmHg increase in pressure
for 1 second x7. The patient expressed
fatigue after performing the test. Mild
substitution using sternocleidomastoid

muscles was palpated at the clavicle.
Neural tissue mobility of the median
nerve was restricted at -45º (R) elbow
extension and -30º (L). Thoracic and
lumbar neural tissue mobility was not
assessed at this time. At the conclusion
of the subjective and objective eva -
luation, no specific contraindications
were identified. 

COURSE OF TREATMENT 
This case study provides a detailed
account of physiotherapy intervention in
a patient with WAD II presenting with
articular, soft tissue, proprioceptive and
postural dysfunction.  Primary goals of
physiotherapy intervention in WAD II
are early mobilization, pain reduction,
optimizing quality of life, patient edu -
cation on behavior modification, quick
return to ADL and reducing a patient’s
dependence on medicine. Positive out-
comes were found with multi-model
physiotherapy intervention, specifically
Maitland/McKenzie mobilizations and
exercises in the recovery from whiplash
injury, prevention of chronic disorders
and controlling social and economic
costs.  In patients with normal recovery,
treatment goals are determined by func-
tional impairments and in patients with
delayed recovery, special emphasis is
placed on coping strategies. 

Table 1 is a detailed description of
the plan of care used for the patient with
WAD II, as described in this case study. 

Special techniques used in proprio-
ceptive and kinesthetic rehabilitation are
based on studies described by Soderlund
et al. 

The patient was treated for six ses-
sions over a 14-day period. Table 2 is a
summary of the outcome measures
before and after physiotherapy inter  -
v en tion.

DISCUSSION
Clinical decision-making is guided by
the patient’s clinical presentation, the
stage of the injury, goals and the
provider’s formal knowledge and expe-
rience. Following a rear-impact collision
of only 5x gravitational force (gs), a sig-
nificant increase in the inter-vertebral
neutral zone and range of motion occurs,
leaving the lower cervical spine, spe -
cifically C5/6 most at risk for injury.
During an acceleration of 3.5gs and
above, facet joint components such as
the synovial fold, articular cartilage and
capsular ligaments are at risk of injury,
due to facet joint compression and
excessive capsular ligament strain during
impact. Facet joint compression that
exceeds physiologic limits could injure
articular cartilage when the upper facet
collides with the lower facet. When the
collision force is enough, irreversible
damage to the cartilage matrix and 
chondrocytes occur.  Mechanoreceptors
in the facet capsule and synovial fold
can be damaged during whiplash causing

Figure 1. The patient’s proprioceptive progression from large to small circles.



4 SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3

Table 1: Physiotherapy intervention and each sessions’ outcome in session one through six.

SESSION 1 (DAY 1)

TREATMENT OUTCOME

Soft tissue mobilization

Mobilization with movement (MWM), preferred direction Decreased pain and muscle guarding 

Joint mobilization 

Passive RSB grade III; Transverse (L) C4 grade II

Patient Education

Encouraged to continue working; Avoid inactivity
leading to the development of chronic pain

SESSION 2 (DAY 2)

Soft tissue mobilization

Continued SB (L/R) = 31º

Joint mobilization SB (L) decreased pain/stiffness

Continued, added UPA (L) C3/4 grade III; Bilateral UPA C3/4, C4/5 grade III Flexion/extension = 45º

Therapeutic Exercise

DNF (20mmHg 5x5sec) Improved neck posture

Scapular retraction      (1x30 with 7kg)

SESSION 3 (DAY 5)

Soft tissue mobilization Plastic response and change in collagen

Continued, added muscle stretching to rhomboids, extensibility
levator scapulae and upper trapezius (L)

Joint mobilization SB (L/R) = 75º.

Extension with bilateral UPA C4/5 Flexion/extension = 95º

Therapeutic Exercise

DNF  (22mmHg 10x5sec)

Scapular retraction (2x30 at 60% of 1RM) Vascularization and opening capillary

Scalene (SB (L), in side laying, 3 x 7 on each side) shunts/collaterals

Patient Education

Posture and pathology of whiplash injuries

Neural Tissue mobilization Stiffness and pain (B) UE decreased

Median nerve  (L); Cervico-Thoracic neural tissue

Home Program

Trapezius/ levator scapulae stretching; Self-mobilization median nerve (B) Plastic response and change in collagen 
adding wrist/elbow extension extensibility

SESSION 4 (DAY 6)

Soft tissue mobilization

MWM (L) scapula; Active/passive pump (L) Trapezius 

Joint mobilization

Transverse (R) C4-C6 grade III; Rotation (L) with SB (L/R) = 62º
UPA (R) C5/6  grade III Total rotation = 88º

Therapeutic Exercise

DNF  (22mmHg 10x10sec)

Scalene   (SB (B) on incline bench) 

Scapular retraction (3x30 60% of 1RM)

Neural tissue mobilization

Lumbar and thoracic in Slump position -30º knee ext (L); -20º knee ext (R) 

Home Program

Neural tissue stretching using “sliders”

Table 1 continued on next page



SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3          5

Table 1: Physiotherapy intervention and each sessions’ outcome in session one through six.

Session 5 (Day 13)

Joint mobilization

UAP (R) C5/6 grade III+ ;Transverse (L) C6 grade III+ Combined SB = 64º;  

Therapeutic Exercise Flexion/extension = 106º

DNF  (24mmHg 5x10sec) Total rotation = 106º

Scalene (Combined SB and Rotation) 

Scapular retraction at wall pulley (2x11 at 80% 1RM)

Neural tissue mobilization Decreased stiffness in trunk and lower back

Sympathetic Slump in long sitting

Kinesthetic awareness

Square corner/diagonal squeezes (3x3sec hold each)

Proprioception Eyes open (black) 30 sec each

Black/red pen in mouth making dots in circles Eyes closed (red) 30 sec each

Home Program

Slump “tensioners” 

Square corner/diagonal squeezes

Session 6 (Day 14)

Joint mobilization Combined SB=62º

UAP (R) C5/6; Combined RSB/ Transverse (L) C6 Total rotation=112º

Therapeutic Exercise Flexion/extension=124º 

DNF (24mmHg 10x10sec)

Scapular retraction at wall pulley (3x7 at 85% 1RM) Improved joint motion around a

(L) Shoulder coordination exercises normal physiological axis

Neural tissue mobilizations

Sympathetic Slump in long sitting with trunk rotation, Decreased stiffness in CT-junction,
adding ankle dorsiflexion as tolerated trunk and lower back

Kinesthetic awareness

Square corner/diagonal squeezes  (5x5sec hold each) Improved neck posture

Proprioception Increased number of red dots

Same as fifth session in smaller circle

Figure 2:  Summary of cervical range of motion changes during physiotherapy sessions.

Normal CROM values Initial Visit

Second visit                    Third visit                      Fourth visit Fifth visit Sixth visit



6 SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3

disruption of proprioceptive transmis-
sion, leading to dysfunction of the 
spinal stabilizing system and the poten-
tial for spinal instability or uncoordinated,
painful muscle contraction,  as well as
inaccurate perception of head and neck
position.  Pain is generated from inflam-
mation in the facet articular cartilage,
synovial fold, ligaments, capsule and
sensitized peripheral and central nocicep-
tive neurons. Sensitization can lead to
lowering nociceptive firing-thresholds,
resulting in pain during normal motion.
Excessive facet joint compression or
capsular ligament strain is likely to lead
to the chronic symptoms associated 
with whiplash injury. Decreased neural
tissue mobility could indicate intra-
neural or intra-dural inflammation, pos-
sibly explaining widespread symptoms
into the thoracic and lumbar areas. 

CONCLUSION
The results of this case report cannot 
be generalized for the WAD II popula-
tion. A definite need for continued
research in physiotherapy intervention
for WAD exists. As far as the author’s
knowledge, the intervention and clinical
reasoning process was in accordance
with current literature on physiotherapy
for WAD II. It is also the author’s
believe that 4-6 additional treatment 
sessions, spread out over the next six
months would have addressed goals not
yet fully accomplished.

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Table 2: A summary of the outcome measures before and after physiotherapy intervention.

Outcome Measures Before Intervention After Intervention

Main Complaint Tight ache in neck, fatigue and Neck slight soreness
soreness in back LBP

Pain Cervical = 4.5/10; Thoracic = 4.5/10 Cervical = 1.5/10; Thoracic = 1.5/10
(NPRS) Lumbar = 4.5/10 Lumbar = 3.5/10

Area of symptoms Sides of neck, between Slight tightness in neck
shoulder blades, LBP Soreness in lower back.

PSFS Turning neck = 7/10 Turning neck = 3/10
Straightening up = 9/10 Straightening up = 3/10
Standing > 15mins = 8/10 Standing > 15mins = 4/10 
Total PSFS = 8/10 Total PSFS = 3.3/10

Patient Goals Relief from back and neck pain Relief from LBP 

Cervical ROM Deficit total range = 250º Deficit total range = 62º 

DNF Pressure Increase: 4mmHg Pressure Increase: 15mmHg
1 second x7 10 seconds x15
Experienced fatigue Good endurance

PAIVM CPA C3-C6, T2-T4 grade 1 UPA (R) C5/6 grade 2
UPA (R) C4/5, C5/6 grade 1 *Transverse (R) C6 grade 2
UPA (L) C3/4, C4/5 grade 1 *Transverse (L) C6 grade 2
*Transverse (R) and (L) C4 grade 1

Median nerve mobility R: -45ºelb extension R: WNL 
L: -30ºelb extension L: WNL