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.
- 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 lead 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 integral (nonadjustable) headrests more effective than adjustable. 6
- During the initial 100 ms 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-joint).
- 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, and have been called “whiplash associated disorders.”
- Subacute and chronic symptoms may also include fatigue, sleep disturbances, depression and anxiety.
- Most injured patients experience rapid recovery after the acute event.
- After 12 months, 20-25% of patients remain symptomatic.9, 10
2. 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, 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. It has acceptable reliability with minimum detectable change of 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. It is interpreted as an interval measurement and has an inconsistent clinically important difference.12
Acute phase will most often demonstrate guarded range of motion in all planes, generalized neck, occipital and upper back tenderness, 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.Chronic whiplash 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.
- 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 (NSAIDs/acetaminophen).
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.
More advanced imaging modalities (MRI, CT) are reserved for suspected cases of nerve root or spinal cord injury. MRI can also detect ligament disruption and subtle or stress vertebral or posterior element fracture.
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 foraminae 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, 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.13
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.
Social role and social support system
Generally speaking, mood affects the perception of symptoms and the appraisal of one’s health14. 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 whiplash.15
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.
There is always a concern from independent treating physicians that a patient with whiplash will have either known or unconscious barriers to recovery because the patient may feel he or she must remain “injured” to collect such a settlement.
Although compensation has been associated with incidence and prognosis, recent literature shows that litigation does not correlate with persistence of pain. 16-18
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, catastrophising, reduced pressure pain threshold at shin, and cervical spine cold hyperalgesia.19
3. 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 and/or heat, home exercises to maintain cervical range of motion, manipulation, mobilization, and a variety of symptomatic medications including nonsteroidal anti-inflammatories, topical analgesics, and acetaminophen
- The use of opioid and muscle relaxant medications in acute cervical whiplash injuries is not shown to improve long-term outcomes and should be limited to several days only.
- With most mild to moderate injuries, the physician should promote an active treatment program and a quick return to normal activity.20
- Many patients will improve after about a month of conservative treatment. Although, the literature suggests that early intensive care (high utilization of physician office visits, physical therapy, chiropractor, massage therapy) is associated with slower recovery, independent of expectation of recovery.21
Chronic/late whiplash syndrome:
- Persistence of neck pain should lead the clinician to evaluation of organic and biopsychosocial factors.22,23
- Prolonged NSAID use does not show long-term benefit and increases risk for gastrointestinal and renal complications.
- Sleep disturbance can exacerbate daily chronic pain. Encourage good sleep hygiene, cervical pillow, and consider sleep aids.
- Consider an antidepressent for clinically relevant hyperalgesia or depression. Consider anticonvulsants for stable neuropathic pain.24
- There is little to no evidence of long-term benefits from narcotic mediation. If prescribing opioids, follow the established guidelines for opioid use in chronic, nonmalignant pain.
- Interventional injections:
- Trigger point injections for myofascial pain syndrome involving the cervical paraspinals and upper trapezeii 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 (level 2 evidence)25.
- Cervical epidural steroid injections can be considered for .
- Manipulation and mobilization:
- Manipulation is broad term which includes modalities such as myofascial releases, counterstrain 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.
- Outcomes after gentle mobilization has been shown to be superior to physical therapy, but no different compared to HVLA. 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.26-29
- 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, Brain death, (<5%). Avoiding extension-based HVLA can minimize the risk of vertebral artery compromise. 30-33
Coordination of care
Multidisciplinary treatment approaches can involve pain management physicians, physical therapists, chiropractors, psychologists and 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” in this situation to 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.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge 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.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
- There is no established and validated grading system for diagnosis or treatment of cervical whiplash associated disorders, although 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 the manipulation 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.
- Radanov BP, et al. Long-term outcome after whiplash injury: a 2-year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings. Medicine. 1995;74:281-297.
- 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.
- McClune T, et al. Whiplash associated disorders: a review of the literature. Emergency Medicine Journal. 2002 Nov; 19(6): 499-506.
- 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.
- McLean S, et al. Incidence and Predictors of Neck and Widespread Pain after Motor Vehicle Collision among US Litigants and Non-Litigants. Pain. February 2014. 155 (2): 309-321. doi: 10.1016/j.pain.2013.10.016.
- 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.
- 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.
- Ludvigsso M, et al. The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: a randomized clinical trial. Clin J Pain. 2015; 31(4): 294-303.
- Curatolo, M. Pharmacological and Interventional Management of Pain After Whiplash Injury. Journal of Orthopedic & Sports Physical Therapy. 2016; 0(0): 1-17. Doi: 10.2519/jospt.2016.6906.
- Manchikanti L, et al. Cervical zygopophysial (facet) joint pain: effectiveness of interventional management strategies. Postgrad Med. 2016; 128(1): 54-68. Doi: 10.1080/00325481.2016. 1105092.
- Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Intern Med 2002; 136:713.
- Hurwitz EL, Morgenstern H, Harber P, et al. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health 2002; 92:1634.
- Gross AR, Hoving JL, Haines TA, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine (Phila Pa 1976) 2004; 29:1541
- Walker MJ, Boyles RE, Young BA, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine (Phila Pa 1976) 2008; 33:2371.
- Shaw L, Descarreaux M, Bryans R, Duranleau M, Marcoux H, Potter B, Ruegg R, Watkin R and White E: A systematic review of chiropractic management of adults with Whiplash-Associated Disorders: Recommendations for advancing evidence-based practice and research. Work 35: 369 394, 2010
- 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
- Verhagen AP, Scholten-Peeters GGGM, van Wijngaarden S, de Bie R, Bierma-Zeinstra SMA. Conservative treatments for whiplash. Cochrane Database Syst Rev. 2007;(2):CD003338. pub 3. doi: 10.1002/14651858.
Original Version of the Topic
Rayden Cody, MD. Cervical Whiplash Disorder. 01/23/2013.
Benjamin Levy, MD
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