Cervical Whiplash is an injury to the cervical spine and supporting structures resulting from an acceleration-deceleration force.
- Cervical whiplash injury has been reported with various impact mechanisms but most frequently occurs as the result of a rear-end or side-impact motor vehicle collision (MVC) typically caused by a rapid acceleration of the body with respect to the head, which results in a horizontal translation at the neck. Subsequently, a rapid correction causes compression, shearing, or tension forces on the cervical spine.
- Less often whiplash is associated with falls, violent collisions in contact sports, or diving.
- Whiplash is also commonly referred to as a cervical sprain or strain. A sprain would be injury to ligaments while strain would be injury to the muscles.
- Experimental model suggests that “limit of harmlessness” for velocity change after rear-end collision is between 5-10 MPH.
- Photographs of involved vehicles are helpful in determining velocity change, although no correlation has been made between type of collision, velocity change, and prognosis. 1,2
Epidemiology including risk factors and primary prevention
- Cervical whiplash injuries are the most common injury observed after motor vehicle collisions.
- The annual incidence of acute symptoms due to a cervical whiplash varies across different countries and is estimated to be between 1 – 6 cases per 1000 population.3
- The prevalence of chronic whiplash pain is estimated to be 1%.3
- One case-control study across nine US states found that 45% of patients with chronic neck pain attributed their pain to a motor vehicle collision.4
- Cervical whiplash injuries have led to a significant socioeconomic cost in many countries leading to numerous attempts to discredit its existence.5
- Head restraints have significantly reduced the number of whiplash injuries related to rear-end collisions with nonadjustable headrests being more effective than adjustable. 6
- During the initial 100 milliseconds after impact, the cervical spine is compressed from below, causing the lower cervical segments to extend while the upper cervical segments are relatively flexed. This results in the cervical spine initially assuming an S-shaped curve prior to all of the cervical segments being forced backwards into extension.7
- Multiple anatomical structures along the cervical spine are potentially injured as the result of a cervical whiplash event, including bones, ligaments, muscles, tendons, discs, and zygapophyseal joints (z-joints or facet joints).
- Injury to the z-joint is widely believed to be the most common source of chronic pain after a cervical whiplash event.8
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
- Up to two-thirds of people involved in MVCs will report neck pain and related symptoms immediately (within several hours post-injury) with another third having a delayed symptom onset of up to 48 hours.
- Initial complaints often include neck and upper back pain. A constellation of other symptoms such as headache, dizziness, concentration and memory disturbances, upper limb weakness and paresthesias, and blurred vision are also frequently seen; these have been called “whiplash associated disorders” (WAD).
- Subacute and chronic symptoms may also include fatigue, sleep disturbances, depression and anxiety.
- Approximately 50% of symptoms resolve in 1-2 weeks, and 90% of symptoms resolve in 6-12 weeks.
- As pain continues into the chronic phase after 3 months, it becomes more difficult to treat.
- Approximately 85% of patients with persistent symptoms may experience symptom recurrence within 1-2 years.
- A study of return-to-work after injury showed 50% of patients to return if they have missed 6 months of work. After 1 year, return-to-work likelihood decreased to 25%. After 2 years of being out of work due to an injury, 0% of patients to return to work.9
Essentials of Assessment
- Detailed history of the collision including patient as driver versus passenger, side of vehicle that was involved, seat belt use, headrests, deployment of airbags, and involvement in litigation.
- Detailed history of initial injury including presence of absence of head injury, loss of consciousness, emergency department evaluation with images, and initial treatments.
- History of present illness and treatments including medications, injections, therapies, modalities, and trials of acupuncture and/or osseous manipulation.
- Determination of associated symptoms including referral of pain down an arm, new numbness or tingling in an arm, weakness, headache, dysphagia, or new gait abnormality.
Assess pre-injury functional status, pain symptomology, and psychological status as pre-accident whole body pain and general psychological distress has been associated with neck pain chronicity.10
The Neck Disability Index11 is a functional outcome measure designed as a checkbox questionnaire scored out of 50 and reported as a percentage. It is often used clinically and in research for acute and chronic neck pain. The minimum detectable change is 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The neck disability index is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health.12
Acute phase will most often demonstrate guarded range of motion in all planes, generalized neck, occipital and upper back tenderness secondary to trapezius and paraspinal dysfunction, and a positive Spurling maneuver if nerve root irritation/injury is present. The presence of strength deficit, reflex asymmetry, or sensory abnormality should be assessed for radiculopathy and/or myelopathy. Chronic WAD without nerve root or spinal cord involvement will generally reveal more localized tenderness in the neck or upper back, cervical extension and rotation pain, and no focal neurological deficits. Headaches typically occur in the acute phase, but chronic WAD is also associated with chronic headaches.
- Typically, routine laboratory studies are not necessary for isolated whiplash injury.
- Certain scenarios would prompt lab testing:
- Consider renal function testing if there is a concomitant thoracic injury. High-velocity impact may cause renal trauma.
- Medical history of renal or hepatic impairment may warrant lab testing prior to initiation of certain pain medications including NSAIDs.
X-rays of the cervical spine at the time of the injury may show age-appropriate degenerative changes and/or straightening of the normal cervical lordotic curve and are usually nondiagnostic. AP and lateral x-rays should be performed to rule out fracture or spondylolisthesis in the case of neurologic deficit and/or loss of consciousness. X-rays may also be considered in the older patient or in high-velocity motor vehicle collisions in the absence of neurologic deficit.
Once the cervical spine has been cleared, if necessary, flexion and extension imaging can be considered if gross instability is suspected. Furthermore, characteristic articular effusion and capsular bulging in addition to any possible osseous abnormalities can be identified with ultrasound. 13
More advanced imaging modalities (MRI, CT) are used for suspected cases of nerve root or spinal cord injury; MRI or CT is also commonly used prior to performing a spine procedure to treat pain. MRI can detect ligament disruption and subtle or stress vertebral or posterior element fracture. Although alar ligament damage has been previously demonstrated in chronic WAD, recent literature showed that MRI can also reveal deep muscle fat infiltration in those at risk of developing chronic WAD.14
Supplemental assessment tools
Upper limb radicular symptoms and/or paresthesias are often noted following cervical whiplash injury. The onset of these symptoms may be immediate or delayed and caused by acute compression in the neural foramina at the time of the collision or from a traumatically induced cervical disc herniation.
After three weeks have elapsed, if radicular symptoms persist, then electrodiagnostic studies can help to identify and quantify injuries to the cervical nerve roots, brachial plexus, and/or peripheral nerves.
Early predictions of outcomes
- Delayed recovery is associated with female gender, older age, high initial intensity of neck pain, neurologic deficit, and preexisting neck pain.
- Recovery is improved by early resumption of pre-injury activities, exercise, manual therapy, and positive attitude. Delayed recovery or chronicity is observed with use of cervical collars, rest, and negative attitudes.15
- Not only did nonrigid cervical collars provide no obvious benefit for recovery but use of these collars was associated with increased time off work.16
- The majority of patients will recover quickly, but a subset of at-risk patients will develop chronic WAD.
Environmental factors including home environment, work status, work-life modifications, community involvement, and current mode of transportation should be considered when creating a treatment plan. If necessary, modifications to motor vehicle should include seatbelts and headrests with adequate height. Energy absorbing seats and active head restraints significantly reduced WAD claims or subjective complaints of neck pain up to 75%.17
Social role and social support system
Generally speaking, mood affects the perception of symptoms and the appraisal of one’s health.18 Often when a person suffers a disabling injury and has chronic pain, the entire family is affected by the injury. Family members can lend encouragement to the injured individual to seek treatment and participate in rehabilitation to restore their function and place within the family dynamic.
Coping style involving the patient actively seeking social support may be associated with shorter duration of whiplash symptoms. Passive coping including internalizing symptoms may be associated with subsequent development of chronic WAD.19
Patients who suffer a cervical whiplash injury as the result of a motor vehicle accident will often obtain legal representation in order to acquire more comprehensive medical treatment as well as seek monetary retribution for their injury.
Sometimes there is concern from independent treating physicians that a patient with whiplash will have either conscious or unconscious barriers to recovery because the patient may feel he or she must remain “injured” to collect such a settlement.
The difference between nations in annual whiplash incidence is significant. Chronic WAD development has been found to be inversely associated with the absence of compensation.20 The elimination of insurance payments for WAD was associated with decreased injury claims. 21 The subjective nature of WAD make insurance settlements and litigation challenging, but medial branch blocks have been cited as an underutilized but objective assessment.22 Although compensation has been associated with incidence and prognosis, recent literature shows that litigation does not correlate with persistence of pain. 23-25
Medical legal literature outlines the following risk factors for poor recovery following whiplash injury: less than post-secondary education, failure to wear a seatbelt, post injury pain >6/10, number and severity of injury related symptoms, presence of radicular symptoms, post injury headache, post injury low back pain, neuropathic pain, Neck Disability Index score >40%, post traumatic stress symptoms, catastrophizing, reduced pressure pain threshold at shin, and cervical spine cold hyperalgesia.26
Rehabilitation Management and Treatments
Available or current treatment guidelines
Treatment guidelines for motor vehicle accident-related whiplash vary from state to state and generally involve stepwise conservative approach to care.
There is a paucity of well-controlled studies for the treatment of acute or late cervical whiplash injury.
- Various initial treatments may include relative rest, ice, home exercises to maintain cervical range of motion, mobilization, and a variety of symptomatic medications including nonsteroidal anti-inflammatories, topical analgesics, and acetaminophen.
- The use of opioid medications in acute cervical whiplash injuries is not shown to improve long-term outcomes and should be limited to no more than 2 days if used; after 5-7 days of opioid use, the risk long term opioid use doubled compared to patients with a prescription of 2 days of opioids or less.27
- With most mild to moderate injuries, the physician should promote an active treatment program and a quick return to normal activity.28
- A population-based inception cohort study of patients with WAD showed that early intensive care is associated with slower recovery; education and reassurance is suggested in the acute phase.29
Chronic/late whiplash syndrome:
- Persistence of neck pain should lead the clinician to evaluation of organic and biopsychosocial factors.30,31
- Prolonged NSAID use does not show long-term benefit; it also has increased risk for gastrointestinal, renal, and cardiovascular complications.
- Sleep disturbance can exacerbate daily chronic pain. Encourage good sleep hygiene, cervical pillow, and consider sleep aids.
- Consider an antidepressant for clinically relevant hyperalgesia or depression. Consider anticonvulsants for stable neuropathic pain.32
- Interventional injections:
- Trigger point injections for myofascial pain syndrome involving the cervical paraspinals and upper trapezius may be helpful in facilitating conservative care.
- The cervical facet joints have been identified as the most common pain generator in chronic neck pain after whiplash injury. Cervical medial branch blocks can assist in determining whether the facet joints are the cause of persistent neck pain.
- Medial branch radiofrequency ablation has long-term effectiveness in managing cervical facet pain.33
- Cervical epidural steroid injections can be considered if symptoms are consistent with cervical radiculopathy and/or irritated disc.
- Occipital nerve blocks can be considered if occipital neuralgia develops or for persistent myofascial pain syndrome.
- Botox injections may also be therapeutic for chronic headaches or myofascial pain.
- Manipulation and mobilization:
- Manipulation is a broad term which includes modalities such as myofascial releases, counter strain and/or indirect or direct muscle energy techniques and high velocity low amplitude (HVLA) thrusts to the cervical spine. The non-HVLA techniques are also commonly referred to as mobilization techniques. Manual manipulation is most commonly performed by osteopathic physicians who are trained in osteopathic manipulative medicine (OMM). Chiropractic practitioners often utilize spinal manipulation in treating patients with whiplash-associated injuries.
- A systemic review concluded that for mechanical neck disorders, manipulation and/or mobilization were more beneficial when utilized in conjunction with exercise rather than when used as an isolated treatment. Also, there is insufficient evidence supporting the effects of mobilization or manipulation in patients with radicular findings.34-37
- There is a baseline low level of evidence supporting chiropractic management of whiplash-associated disorders. Over 400 reported cases of adverse events after cervical manipulations include arterial dissection (20%), brain stem injury (18%), Wallenberg syndrome (12%), cerebellar injury (10%), spinal cord injury, thrombosis, locked in syndrome (<10%); Horner’s syndrome, joint dislocation, and brain death (<5%). Avoiding extension-based HVLA can minimize the risk of vertebral artery compromise. 38-41
Coordination of care
Multidisciplinary treatment approaches can involve pain management physicians, primary care physicians, physical therapists, chiropractors, psychologists, psychiatrists, social workers, acupuncturists, and other allied health personnel who can work together for the benefit of the patient. It is the physiatrists’ job to “drive the bus.” He or she should lead the treatment team and coordinate these treatments.
Patient & family education
The patient should be educated and reassured regarding the normal healing process and the favorable natural history of most acute cervical whiplash injuries. Early resumption of pre-injury activities, positive attitudes for recovery, range of motion exercises, and gentle mobilization should be encouraged. For those who have become chronic and disabled, involving the family may be essential to turning the condition around and getting the patient to participate in active rehabilitation programs.
If the patient appears to have persistent functional deficits and has reached maximum medical improvement, the American Medical Association Guides to the Evaluation of Permanent Impairment can be used to quantify the percentage of whole body impairment.
Cutting Edge/ Emerging and Unique Concepts and Practice
- In the future, regenerative medicine may have a role in the interventional options for chronic neck pain.
- Currently, there is no literature supporting or refuting the role of stem cell or platelet rich plasma therapies in the setting of whiplash.
Gaps in the Evidence- Based Knowledge
- Despite the Quebec Task Force classification being utilized, there is currently no established and validated grading system for diagnosis or treatment of cervical whiplash associated disorders. New clinical prognosticators have been investigated.
- Treatment guidelines are difficult as this is not a homogenous injury.
- Treatment plans require individual considerations and access to resources.
- Further research on the cost effectiveness of these strategies may guide practice patterns and bolster support for treatments not typically covered by insurers.
- Castro WH, et al. Do “whiplash injuries” occur at low-speed rear impacts? Eur Spine Journal. 1997; 6(6): 366-75
- Bunketorp OB, et al. Cervical status after neck sprains in frontal and rear end impacts. Injury. 2013. April; 43 (4): 423-30. Doi: 10.1016/j.injury.2011.05.020. Epub 2011 June 16.
- Barnsley L, Lord SM, Bogduk N. Whiplash injury. Pain.1994;58:283–307.
- Freeman MD, et al. Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain. Pain Research and Management. 2006; 11(2): 79-83.
- Malleson A. Whiplash and Other Useful Illnesses. Montreal, Canada: McGill-Queen’s University Press. 2002:p527.
- Kahane, C. An evaluation of head restraints. Federal Motor Vehicle Safety Standard 202. NHTSA Report number DOT HS 806 108. http://www.nhtsa.gov/cars/rules/regrev/evaluate/806108.html
- Kaneoka K, et. al. Abnormal segmental motion of the cervical spine during whiplash loading. J Jap Orthop Assoc. 1997;71(suppl):S1680.
- Barnsley L, et al. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine. 1995;20(1):20-25;discussion 26.
- Cuccurullo S. Physical medicine and rehabilitation board review. Fourth ed. New York: DemosMedical; 2019.
- Atherton K, et al. Predictors of persistent neck pain after whiplash injury. Emergency Medicine Journal. 2006; 23: 195-201. Doi: 10.1136/emj.2005.027102.
- Vernon H, et al. The Neck Disability Index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics. 1991. 14; 409-415.
- Macdermid J, et al. Measurement Properties of the Neck Disability Index: a Systemic Review. Journal of Orthopedic & Sports Physical Therapy, 2009. 39(5): 400-C12. Doi: 10.2519/jospt.2009.2930.
- Galletti S, Galletti R, Schiavone C, Salini V, Abate M. Localized cervical pain: advantages and limits of ultrasound evaluation. J Ultrasound. 2016;19(4):257-263. Published 2016 Apr 13. doi:10.1007/s40477-016-0207-4
- Elliott JM, Smith AC, Hoggarth MA, et al. Muscle fat infiltration following whiplash: A computed tomography and magnetic resonance imaging comparison. PLoS One. 2020;15(6):e0234061. Published 2020 Jun 2. doi:10.1371/journal.pone.023406
- McClune T, et al. Whiplash associated disorders: a review of the literature. Emergency Medicine Journal. 2002 Nov; 19(6): 499-506.
- Ricciardi L, Stifano V, D’Arrigo S, Polli FM, Olivi A, Sturiale CL. The role of non-rigid cervical collar in pain relief and functional restoration after whiplash injury: a systematic review and a pooled analysis of randomized controlled trials. Eur Spine J. 2019;28(8):1821-1828. doi:10.1007/s00586-019-06035-9
- Ivancic PC. Does knowledge of seat design and whiplash injury mechanisms translate to understanding outcomes?. Spine (Phila Pa 1976). 2011;36(25 Suppl):S187-S193. doi:10.1097/BRS.0b013e3182387eff
- Crolye RT, Uretsky MB. Effects of mood on self-appraisal of health status. Health Psychol. 1987;6:239-253.
- Buitenhuis J, et al. Recovery from Acute Whiplash: The Role of Coping Styles. Spine. 2003; 28(9): 896-901.
- Schrader H, Obelieniene D, Bovim G, et al. Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet. 1996;347(9010):1207-1211. doi:10.1016/s0140-6736(96)90733-3
- Holm LW, Carroll LJ, Cassidy JD, et al. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(4 Suppl):S52-S59. doi:10.1097/BRS.0b013e3181643ece
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- Cassidy J, et al. Effect of Eliminating Compensation for Pain and Suffering on the Outcome of Insurance Claims for Whiplash Injury. The New England Journal of Medicine. April 2000. 343 (16): 1179-1186.
- Spearing N, et al. Reseach on injury compensation and health outcomes: ignoring the problem of reverse causality led to a biased conclusion. Journal of Clinical Epidemiology. 2012. 65: 1219-1226.
- Worsfold, C. When range of motion is not enough: Towards an evidence-based approach to medico-legal reporting in whiplash injury. Journal of Forensic and Legal Medicine. 2014. 25: 95-99.
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- Rosenfeld M, et al. Active intervention in patients with whiplash-associated disorders improves long-term prognosis: a randomized controlled clinical trial. Spine. 2003;28(22):2491 – 2498.
- Skillgate E, et al. Effect of Early Intensive Care on Recovery from Whiplash Associated Disorders: Results of a Population-Based Cohort Study. Archives of Physical Medicine and Rehabilitation. 2016; 97(5): 739-746.
- Poorbaugh K, et al. Late whiplash syndrome: a clinical science approach to evidence-based diagnosis and management. Pain Practice. 2008; 8(1): 65-87.
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- Di Fabio RP. Manipulation of the Cervical Spine: Risks and Benefits. Physical Therapy 1999;79:50-65.
- Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. Spine 2002;27:49-55.
- Dufton JA, et al. Prognostic factors associated with minimal improvement following acute whiplash-associated disorders. Spine. 2006;31 (20):E759–765. doi: 10.1097/01.brs.0000240205.93122.02
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Original Version of the Topic
Rayden Cody, MD. Cervical Whiplash Disorder. 1/23/2013.
Previous Revision(s) of the Topic
Benjamin Levy, MD. Cervical Whiplash. 4/5/2017.
Casey A. Murphy, MD
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Eric Stockwell, MD
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