Whiplash Injuries, Part 2: Symptoms, Examination and Diagnosis
Understanding Whiplash Symptoms and Diagnosis
Whiplash-associated disorders can present in many different ways. Neck pain and stiffness are common, but some people may also experience headaches, dizziness, altered sensation, weakness, reduced movement, balance disturbances, or difficulty performing normal activities.
In Part 1, we examined what happens to the cervical spine and surrounding tissues during a collision. Part 2 moves from the mechanism of injury to the clinical presentation: what symptoms are present, what the examination may reveal, and how these findings help guide diagnosis and management.
We will also look at the Whiplash-Associated Disorders (WAD) classification system, which organizes whiplash presentations according to symptoms and clinical findings. While this classification can help describe a patient's presentation, a thorough assessment should consider the individual as a whole rather than relying on a classification alone.
Article Index
Identifying Symptoms of Whiplash Injury
Whiplash-associated disorders can produce a wide range of symptoms. Neck pain and stiffness are the most common, but symptoms may also involve the head, jaw, shoulders, upper back, arms, and other regions of the body.
Symptoms may be present immediately after a collision or become more noticeable over the following hours or days. Their pattern and intensity can also change during recovery. Because many of these symptoms have more than one possible cause, they should be considered as part of the overall clinical presentation rather than automatically attributed to a specific injured structure.
Common symptoms may include:
Neck pain and stiffness: Often accompanied by reduced or painful cervical movement.
Headache: May involve the back of the head, upper neck, temples, forehead, or other regions. Several types of headache can occur following a collision and should be differentiated clinically.
Jaw and facial symptoms: Jaw pain, altered movement, or symptoms consistent with temporomandibular disorders (TMD) may occur following trauma.
Shoulder and upper-back pain: Pain may extend across the shoulders or between the shoulder blades and can arise from several musculoskeletal or neurological sources.
Arm pain: Symptoms extending into the arm may involve local musculoskeletal tissues, cervical nerve roots, peripheral nerves, or referred pain.
Additional Whiplash Symptoms
Whiplash-associated disorders are not limited to pain. Depending on the circumstances of the collision and the individual presentation, other symptoms may include:
Paresthesia: Tingling, numbness, burning, or other altered sensations, particularly in the shoulders, arms, or hands. Neurological symptoms warrant appropriate assessment.
Dizziness and balance disturbances: These can have cervical, vestibular, neurological, visual, cardiovascular, medication-related, or concussion-associated contributors.
Sleep disturbance: Pain, stress, changes in activity, and other factors following an injury can interfere with sleep.
Fatigue: Some people experience persistent or increased fatigue following a collision.
Low-back pain: Motor vehicle collisions can affect regions well beyond the cervical spine.
Concentration or memory difficulties: Cognitive symptoms may occur following a collision and should prompt consideration of concussion and other contributing factors when clinically appropriate.
Psychological symptoms: Anxiety, low mood, post-traumatic stress symptoms, or fear related to movement or driving can occur following a motor vehicle collision and may influence recovery.
Tinnitus: Ringing, buzzing, or other perceived sounds may occur and can have several possible causes.
Visual disturbances: Blurred vision, difficulty focusing, light sensitivity, or other visual symptoms may occur and require appropriate assessment.
Weakness: A feeling of weakness can accompany pain and reduced activity. Objective or progressive muscle weakness, particularly when associated with sensory changes or altered reflexes, requires neurological assessment.
Physical Examination
A clinical assessment following a motor vehicle collision helps determine the nature of the injury, identify findings that may require further investigation, and guide appropriate management. The examination should be based on the history, symptoms, mechanism of injury, and individual clinical presentation rather than applying the same series of tests to every patient.
Depending on the presentation, assessment may include musculoskeletal, neurological, vascular, concussion, and vestibular examination. Particular attention should be given to progressive neurological symptoms, significant trauma, unusual headache or neck pain, altered consciousness, or other findings that may indicate the need for urgent medical assessment or imaging.
The following videos demonstrate several components that may be incorporated into the examination when clinically appropriate.
Musculoskeletal Assessment
Cervical Examination
The cervical examination evaluates the neck and surrounding musculoskeletal structures following injury. Assessment may include observation, palpation, active and passive movement, and selected orthopaedic tests based on the patient's symptoms and clinical presentation.
Rather than relying on any single test, findings are interpreted together with the history and other components of the examination to help determine the most appropriate course of care.
Neurological Assessment
Neurological examination becomes particularly important when symptoms such as numbness, tingling, weakness, altered reflexes, radiating arm pain, balance disturbances, or other neurological findings are present.
Cranial Nerve Examination
A cranial nerve examination assesses sensory and motor functions associated with the twelve cranial nerves. Following a motor vehicle collision, this examination may be appropriate when symptoms such as visual disturbance, facial sensory changes, dizziness, swallowing or speech difficulties, abnormal eye movements, or other neurological findings raise concern.
Abnormal findings may indicate the need for additional medical or neurological investigation.
Upper Limb Neuro Exam
An upper-limb neurological examination evaluates motor function, sensation, and reflexes associated with the cervical nerve roots and peripheral nerves.
This examination can help distinguish between different potential sources of arm pain, numbness, tingling, or weakness and determine whether further neurological investigation is appropriate.
Vascular Assessment
Peripheral Vascular Examination
Vascular assessment may be appropriate when the history or symptoms raise concern about circulation or vascular injury. Examination can include assessment of pulses, circulation, skin changes, and comparison between the upper extremities.
More importantly following cervical trauma, sudden unusual headache or neck pain accompanied by neurological symptoms, visual disturbance, difficulty speaking or swallowing, severe dizziness, loss of coordination, or other concerning findings requires appropriate medical evaluation.
Concussion, Dizziness and Vestibular Assessment
Dizziness, balance disturbance, visual symptoms, headache, difficulty concentrating, and other neurological symptoms can occur following a motor vehicle collision. These symptoms may have several possible causes, including concussion, vestibular dysfunction, cervical sensorimotor disturbance, BPPV, migraine, medication effects, or, less commonly, more serious neurological or vascular conditions.
For this reason, assessment should be guided by the patient's symptoms and clinical presentation. No single test can diagnose concussion or determine the cause of dizziness. The following examinations assess different aspects of the vestibular and neurological systems and are used when clinically appropriate.
VOMS
The Vestibular/Ocular Motor Screening (VOMS) assessment evaluates symptom responses during tasks involving eye movements, visual motion, and vestibular function. It includes smooth pursuits, saccades, convergence, vestibular-ocular reflex testing, and visual motion sensitivity.
VOMS can help identify vestibular and ocular-motor symptoms associated with concussion and can contribute to a broader concussion assessment. It is a screening tool and should not be used by itself to diagnose or exclude concussion.
HINTS Exam
The HINTS examination combines the Head Impulse Test, assessment of Nystagmus, and Test of Skew. It was developed for the evaluation of patients presenting with acute vestibular syndrome, typically characterized by persistent acute dizziness or vertigo accompanied by findings such as nystagmus, nausea or vomiting, and gait instability.
When performed by appropriately trained clinicians in the correct clinical setting, HINTS can help distinguish certain peripheral vestibular disorders from central neurological causes such as stroke.
HINTS is not a routine concussion or general dizziness screening examination, and its findings must be interpreted within the appropriate clinical context.
Dix HallPike Maneuver - Vertigo
The Dix-Hallpike maneuver is used when benign paroxysmal positional vertigo (BPPV) is suspected, particularly posterior-canal BPPV.
BPPV produces brief episodes of vertigo triggered by changes in head position. The Dix-Hallpike maneuver attempts to reproduce the characteristic vertigo and nystagmus associated with posterior-canal BPPV and can help establish the diagnosis.
Because dizziness following a motor vehicle collision can have several potential causes, a positive or negative Dix-Hallpike test should be interpreted as one component of the overall clinical assessment.
Diagnostic Imaging
Diagnostic imaging is not routinely required for every whiplash injury. Many people with uncomplicated whiplash-associated disorders can be assessed through their history and physical examination without immediate imaging.
The decision to obtain imaging should be based on the mechanism of injury, clinical findings, neurological symptoms, red flags, and whether the results are likely to influence diagnosis or management. When acute cervical spine injury is a concern, validated clinical decision rules can also help determine whether imaging is appropriate.
Depending on the clinical presentation, imaging may include:
Radiographs (X-rays): May be used in selected cases to evaluate the cervical spine when fracture, dislocation, or other bony abnormality is a concern. Their use depends on the clinical situation and applicable imaging guidelines.
Computed Tomography (CT): Provides detailed visualization of bone and is particularly useful when an acute cervical fracture is suspected. In significant trauma, CT may be preferred over conventional radiographs when imaging of the cervical spine is required.
Magnetic Resonance Imaging (MRI): Provides detailed visualization of the spinal cord, nerve roots, discs, ligaments, and other soft tissues. MRI may be appropriate when there are significant or progressive neurological findings, suspected spinal cord or ligamentous injury, or persistent symptoms when the results are expected to influence management.
Imaging findings must always be interpreted in the context of the patient's symptoms and examination. Disc degeneration, disc bulges, facet changes, and other structural findings can also occur in people without neck pain and may represent age-related changes rather than injuries caused by the collision.
Suspected fracture, dislocation, spinal cord involvement, progressive neurological deficits, or other signs of serious injury require prompt medical evaluation and appropriate imaging.
Classification of Whiplash-Associated Disorders (WAD)
The Quebec Task Force classification provides a standardized way of describing Whiplash-Associated Disorders based on neck symptoms and findings identified during clinical examination. The system ranges from Grade 0, where there are no neck complaints or physical signs, to Grade IV, where fracture or dislocation is present.
The classification can help healthcare professionals communicate clinical findings and categorize the presentation, but the WAD grade is only one part of the assessment. Symptoms such as headache, dizziness, tinnitus, memory difficulties, swallowing problems, and temporomandibular symptoms may occur across different WAD grades and should be evaluated separately when present.
The WAD classification includes:
Grade 0: No neck complaint and no physical signs.
Grade I: Neck pain, stiffness, or tenderness is reported, but there are no physical signs on examination.
Grade II: Neck symptoms are accompanied by musculoskeletal findings, such as decreased cervical range of motion or point tenderness.
Grade III: Neck symptoms are accompanied by neurological findings, which may include decreased or absent tendon reflexes, muscle weakness, or sensory deficits.
Grade IV: Neck symptoms are accompanied by a fracture or dislocation.
Looking Beyond the WAD Grade
The WAD classification is useful for describing clinical findings, but two people with the same WAD grade can have very different symptoms, levels of disability, and recovery trajectories. Assessment should therefore consider the broader clinical picture, including pain, function, neurological findings, dizziness or balance disturbances, psychological factors, and the individual's progress over time. Current guidelines likewise use measures beyond WAD grade to assess disability and factors associated with recovery.
Chapter 2: Conclusion
Whiplash-associated disorders can present very differently from one person to another. Neck pain and stiffness are common, but headache, dizziness, neurological symptoms, balance disturbances, cognitive symptoms, jaw pain, and other complaints may also occur following a motor vehicle collision.
A careful history and clinical examination help determine which findings are relevant and whether further neurological, vestibular, vascular, concussion, or imaging assessment is appropriate. No single symptom, physical test, or imaging finding should be interpreted in isolation.
The WAD classification system provides a useful framework for describing neck symptoms and clinical findings, but it represents only one part of the assessment. Understanding the individual's symptoms, function, neurological status, and progress over time provides a more complete clinical picture.
Part 3 moves from assessment to recovery, examining treatment options, manual therapy, exercise, progressive rehabilitation, and strategies for returning to normal activities.
References
American College of Radiology. (2024). ACR Appropriateness Criteria®: Acute Spinal Trauma. American College of Radiology.
Bhattacharyya, N., Gubbels, S. P., Schwartz, S. R., Edlow, J. A., El-Kashlan, H., Fife, T., Holmberg, J. M., Mahoney, K., Hollingsworth, D. B., Roberts, R., Seidman, M. D., Steiner, R. W. P., Do, B. T., Voelker, C. C. J., Waguespack, R. W., & Corrigan, M. D. (2017). Clinical practice guideline: Benign paroxysmal positional vertigo (update). Otolaryngology–Head and Neck Surgery, 156(3 Suppl), S1–S47.
Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y. H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504–3510.
Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., Marchetti, G., & Kontos, A. P. (2014). A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: Preliminary findings. The American Journal of Sports Medicine, 42(10), 2479–2486.
Spitzer, W. O., Skovron, M. L., Salmi, L. R., Cassidy, J. D., Duranceau, J., Suissa, S., & Zeiss, E. (1995). Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: Redefining “whiplash” and its management. Spine, 20(8 Suppl), 1S–73S.
Stiell, I. G., Wells, G. A., Vandemheen, K. L., Clement, C. M., Lesiuk, H., De Maio, V. J., Laupacis, A., Schull, M., McKnight, R. D., Verbeek, R., Brison, R., Cass, D., Dreyer, J., Eisenhauer, M. A., Greenberg, G. H., MacPhail, I., Morrison, L., Reardon, M., & Worthington, J. (2001). The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA, 286(15), 1841–1848.
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DR. BRIAN ABELSON DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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