June 10, 2022
Whiplash injuries can occur when the energy or force involved in sudden acceleration and deceleration is transferred to the neck. Often associated with motor vehicle accidents, whiplash can also occur during slips, falls or sports-related activities in which a blow to the head occurs.
Whiplash that involves injuries to bony or soft tissue in the neck can lead to a variety of clinical manifestations, including neck pain, stiffness, sensorimotor dysfunction, psychological disturbance, disequilibrium, cognitive issues, sleep disturbance and pain in other parts of the body.
According to Randy A. Shelerud, M.D., a physiatrist at Mayo Clinic's Spine Center in Rochester, Minnesota, patients with a whiplash injury may present with a wide variety of symptoms known as whiplash-associated disorders (WAD). The Quebec Classification of Whiplash-Associated Disorders, published in Spine in 1995, divides WAD into grades 0 to 4, based on severity.
According to Dr. Shelerud, many WAD symptoms resolve within three months. However, it has been estimated that up to 50% of patients with WAD report pain lasting for months or years after the time of injury. And up to 30% of these patients have persistent moderate to severe pain and disability that may significantly impact their lives. Chronic WAD is commonly defined in the literature as symptoms that persist for three months or longer.
"The trajectories of patients who experience chronic symptoms reflect the somewhat limited success of currently available treatments for acute whiplash," explains Dr. Shelerud. "However, there is strong evidence that both verbal education and written advice can help reduce pain and disability and improve mobility."
Exercise and activity
Most patients seeking care in the outpatient setting want to know when they can remove the cervical collar and what they can and cannot do. Dr. Shelerud emphasizes that early physical activity and correct posture are superior to rest and neck collars.
"Although prescribing collars and rest were the mainstay of emergency department recommendations in the past, there's strong evidence that immobilization is ineffective for the management of acute WAD. Pain is normal after whiplash, so I encourage the use of analgesics to treat that pain, and I recommend avoiding collar use and focusing on mobility. Educational videos also have a profound effect on subsequent pain and medical utilization compared with usual care."
Dr. Shelerud notes that the cervical collar can be discontinued if there's no midline tenderness. Patients with midline tenderness, however, require additional assessment.
Patients with more than 30 degrees of active flexion and extension should undergo flexion and extension X-rays to look for dynamic spinal instability. "Although this finding is rare, it's important to rule it out," explains Dr. Shelerud. Patients with less than 30 degrees of active flexion or extension should undergo a cervical spine MRI.
Dr. Shelerud notes that multiple studies show that active physical therapy regimens are effective in decreasing pain and disability. "These programs can include exercises to improve range of motion, cervical muscle strengthening and endurance, coordination training, and functional capacity," says Dr. Shelerud.
According to Dr. Shelerud, scientific evidence demonstrating the efficacy medications for treatment of acute and chronic WAD symptoms is still limited. Until more data is available, practitioners can consult expert consensus-driven guidelines, some of which are summarized below.
- Acute WAD grade 1 — No medication other than simple analgesics. Opioid analgesics are not recommended.
Acute WAD grades 2 and 3 — Nonopioid analgesics and nonsteroidal anti-inflammatory medications (NSAIDs), limited to three weeks and weighed against known side effects, which appear to be dose-related. Opioids for severe pain (a visual analog scales pain rating score of more than 8) for a limited period of time, such as 1 to 2 weeks.
"In general, muscle relaxants have shown no efficacy when used alone or in combination with nonsteroidal anti-inflammatory medications," says Dr. Shelerud. "Similarly, there is little evidence that systemic steroids (intramuscular or intravenous) offer more symptom relief for acute WAD than placebos."
- Subacute or chronic WAD — There is no research data specific to the management of this type of WAD-related pain. In studies on chronic neck pain, muscle relaxants, analgesics and nonsteroidal anti-inflammatory medications had limited evidence and unclear benefits. "Tricyclic antidepressants at bedtime, or dual reuptake inhibitor antidepressants duloxetine and venlafaxine, can be considered, but the evidence on the efficacy of these treatments is mixed," says Dr. Shelerud.
Complementary medicine and injection therapies
Dr. Shelerud notes that currently there is a lack of quality published evidence demonstrating the efficacy of spinal manual therapy, botulinum toxin type A injections and nerve blocks for the treatment of WAD. But these approaches can be used in conjunction with exercise and advice if there is evidence of continued benefit. For example, trigger point injections delivering medication into tender neck muscles may be an option for selected patients. Finally, the use of acupuncture in this patient population awaits research support.
Evidence continues to grow regarding the use of radiofrequency ablation (RFA) to block pain from cervical facet joints in patients with whiplash. In one systematic review, approximately half the patients with chronic whiplash-related neck pain were found to respond to RFA.
Cognitive issues seen in patients with WAD or concussion have considerable overlap. Newer studies point to the impact of the head on the head restraint in motor vehicle collisions as the cause. Therefore, the treating provider must assess for concussive symptoms in patients with whiplash and consider referring them to brain injury clinics.
Approximately 25% of patients with whiplash experience significant distress or post-traumatic stress disorder (PTSD) related to their involvement in a car accident. Individuals with WAD may also experience fear of movement, centrally mediated pain or central nervous system sensitization, and other factors that can hinder recovery.
"To address these issues," explains Dr. Shelerud, "multiple clinical trials have demonstrated that some patients with WAD may benefit from cognitive behavioral therapy techniques and CBT-based pain rehabilitation programs."
For more information
The Quebec Classification of Whiplash-Associated Disorders*. Spine. 1995;20:6S.
Refer a patient to Mayo Clinic.