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3 Articles in Volume 2, Issue #5
A Conceptual Model of Pain
Taxonomy of Pain Patient Behavior
Whiplash Injuries in Motor Vehicle Accidents

Whiplash Injuries in Motor Vehicle Accidents

A comprehensive survey of whiplash-related musculoskeletal injuries, diagnoses, and treatment modalities.

Motor vehicle accidents are the most common mechanism of trauma and are frequently associated with musculoskeletal injuries. In the United States, trauma is a major cause of death in persons less than 40 years of age, and motor vehicle accidents account for 42,000 deaths annually, with an annual cost of $14 billion.1 Statistics show that 85% of traumatic neck injuries are due to motor vehicle accidents, and there is a higher prevalence in females.2

With the design of vehicles, seat belts, shoulder harnesses, air bags, head rests and child seats, the safety of passengers has improved significantly resulting in reduced critical injuries. However, air bags do not decrease the likelihood of significant lower extremity trauma which may result in death from minimal impacts, particularly in those individuals who are short. With a general reduction in critical injuries, there is a greater proportion of soft tissue injuries including strains, sprains, contusions, abrasions and lacerations following motor vehicle accidents.2

Mechanism and Pathophysiology

Cervical whiplash is considered a soft tissue injury involving the muscles, tendons, ligaments, and facet joints. Dr. H. Crowe described whiplash in 1928 as an acceleration/deceleration mechanism of energy transfer to the neck. This term has a negative connotation, and is better described as a musculoligamentous injury to the cervical spine.3 An impact of 2-5 mph is sufficient to produce enough force to result in musculoskeletal injury, which may be transient.4 Forces on the head, which weighs about 13 pounds, can be 3 to 14 times the acceleration of gravity, resulting in musculoskeletal injuries to the relatively thin, rod-like cervical spine and other vulnerable joints (i.e. jaw).5 The injuries sustained are, in part, based on the relative mass and speed (inertia) of both vehicles involved, as well as the displacement that occurs during impact. The literature suggests that there is less injury to the cervical spine during hyperflexion due to the limiting factor of the chin hitting against the chest. Thus, low velocity front-end collisions tend to result in less disability than rear-end collisions. It is difficult to predict, based on the mechanism of accident and property damage, the extent of a passenger’s injury. Some studies suggest that an occupant who sustains a rear-end collision is more likely to have symptoms of cranial nerve or brain stem dysfunction. In many neck injuries, there is also a rotational component, which may be related to the position of the neck, or oblique force vectors at the moment of impact, resulting in greater compressive forces to the facet joints and nerve roots. There is also a vertical force component, lifting the victim upward, which may affect the location of the headrest during the hyperextension phase. Following a motor vehicle accident, unprepared occupants have a higher frequency of multiple symptoms including headaches.1

A sprain is a tear or stretch injury to the ligaments. During forced extension or lateral bending of the cervical spine, there may be a tear of the anterior longitudinal ligament, which may also result in compressive forces to the posterior elements of the spine. This, in turn, may result in stretch or hemarthosis of the cervical facet joints. In forced flexion, there may be a tear of the inter-spinous ligament. Healing of the ligaments can result in fibrosis, with reduced elasticity and restricted joint motion, which may make the patient more susceptible to recurring injuries from relatively mild trauma. A musculotendonous strain is a stretch injury to the tendon, myofascial sheaths and muscles. Pathologically, there may be tears, or even rupture, resulting in local tissue hemorrhage and may ultimately result in fibrosis. In more severe injuries, particularly if there is head trauma, there may be 1) disruption of the annular fibers of the anterior cervical disk through shearing forces and forced extension, 2) injury to the cervical sympathetic nerve fibers during forced extension, 3) vertebral artery spasm during forced extension with lateral bending, and 4) vertebral fractures as the result of compressive forces to the anterior elements.3

Symptoms and Evaluation

A patient who presents with acute whiplash generally complains of:

  • neck pain (90-100%)
  • restricted neck range of motion (40-95%)
  • headaches (50-90%)
  • referral into the shoulder and arm (40-70%)
  • radiating symptoms (10%)
  • hand paresthesias (10-15%)
  • upper extremity paresthesias (45%)
  • back pain (35%)
  • dizziness or unsteadiness (20-70%)
  • blurred vision (20-45%)
  • photophobia (30-80%)
  • tinnitus (4%)
  • nonspecific upper extremity weak ness or generalized fatigue (60%)
  • anxiety (45-50%)
  • depression (45%)
  • irritability (20%)
  • impaired concentration (20-60%)
  • insomnia (35%)
  • dysphagia (7%)
  • sexual dysfunction (7%)
  • myelopathy (4%)

If there is a cervical disk disruption, it may result in radiating symptoms into the upper extremity associated with focal weakness, reflex changes and sensory deficits. If the cervical disk disruption affects the spinal cord, then the patient may present with myelopathy, including spasticity, bowel, bladder, sexual, and gait dysfunction.1,2,6

The Quebec taskforce in 1995 classified the severity of cervical sprain as in Table 1.6

An appropriate history is important to exclude significant pathology affecting the neck including spinal cord, nerve root, head injury, fractures and hematomas. An appropriate physical examination includes a complete musculoskeletal and neurologic assessment, with careful attention in evaluating the soft tissue findings including a posture, restricted range of motion, myofascial trigger points, subtleties in weakness and imbalance of muscles.

With grade 2 or more injuries, the patient will present with guarded and restricted neck motions, often associated with cervical paraspinal muscle spasm. There is usually palpable tenderness in the muscles, fascia, tendons, which may, in turn, elicit a characteristic referral pattern of pain, numbness or tenderness known as a myofascial pain syndrome. Frequently, the muscles involved during the hyperextension component are the sternocleidomastoid (SCM) and scalene, particularly if the headrest was not adjusted properly, and during the hyperflexion component, the trapezius, levator scapulae and cervical paraspinals are affected. Often, these patients present with contralateral pain on neck rotation, bending and flexion. There are some patients that present with post-traumatic cervical torticollis, possibly related to excessive hypertonicity of the SCM muscle, and may require anticholinergics or botulinum toxin injections. There may also be segmental hyper- or hypo-mobility of the facet joints often manifested by unilateral pain with neck rotation, bending and extension.

Grade 3 patients include those with discogenic etiologies, and often present with ipsilateral pain with neck rotation, bending and flexion. It should be noted that in certain patients, the symptoms are not manifested until several days or even weeks following the injury. This may be related to activation of latent trigger points (to be discussed later). The patient’s presentation may include several pain generators and may change over time, requiring the clinician to perform serial examinations on the patient.

The Quebec taskforce classifications for the severity of cervical sprains
Grade Presentation
0 No neck pain complaints, no physical signs
1 Neck pain complaints, stiffness or tenderness only, no physical signs
2 Neck complaints and muscoloskeletal signs*
3 Neck complaints and neurologic signs**
4 Neck complaints with fracture and/or disclocation

It is also important to evaluate the patient’s functional status and his psychological response to his injury. The determination of how this injury affects the patient’s self care, mobility, work, recreation, sexual function and sleep are important in determining treatment recommendations. In addition, an assessment of the patient’s pain coping abilities, anxieties including fear of driving, medicolegal issues, and financial disincentives can assist in determining a comprehensive interdisciplinary treatment program to accommodate the patient’s global needs. It is my opinion that residual disability can be minimized with early intervention in an intensive comprehensive program including multimodality physical medicine, home exercises, and appropriate counseling7.

Diagnostic Assessment

A diagnostic evaluation of the patient should be performed if there are any neurologic signs, symptoms or guarded and significantly restricted motions. It should also be noted that with an acute neck injury, the victim should minimize any motions to the neck with an immobilization — utilizing a board and collar — until they are formally evaluated by a physician or paramedic, and x-rays have revealed no fracture. Cervical spine x-rays including the antero-posterior, lateral and C1-C2 views should be obtained. Oblique views should be considered in older patients with concerns of nerve root impingement, as the result of neural foramen encroachment usually caused by osteophytes and manifested by ipsilateral pain with neck rotation, bending and extension in conjunction with neurologic signs or symptoms.

A Jefferson fracture is a burst fracture of the ring of the C1, and is usually associated with neurologic deficits. A hangman’s fracture involves the neural arch of C1. Odontoid fractures occur with shearing, and may result in spinal cord injury, requiring C1-C2 (open mouth) views for diagnosis. The clay shoveler’s fracture is an avulsion fracture of the spine, and is usually “stable.”

If there is concern of cervical spine instability, then flexion extension views should be obtained. It should be cautioned that diagnostic testing must be clinically correlated to the patient’s symptoms and signs, and abnormalities do not necessarily indicate that this is the source of their pain. Commonly, x-rays will show straightening of the cervical spine (reduced cervical lordosis), which is a result of cervical paraspinal muscle spasm, and is a protective mechanism to restrict range of motion of a joint.3 X-rays performed 10 years following cervical spine injury have shown up to a 39% higher prevalence of degeneration. There is also a tendency for hypermobility of the facet joints which may pre-dispose to cervical spine instability. Degenerative changes, if present at the initial x-ray are usually preexisting, but may pre-dispose the patient for a prolonged convalescence as a result of segmental dysfunction with restricted range of motion and an imbalance of muscles. The literature suggests that patients with preexisting neck pathology or pain have a prolonged recuperation following motor vehicle accidents.1 If there are concerns of spinal cord injury, then an urgent cervical MRI should be obtained. In persistent neck pain, with neurologic signs or symptoms despite appropriate conservative care, a cervical MRI should be obtained. Up to 33 percent of these patients show disk abnormalities by MRI, primarily at the C4-5 and C5-6 levels, with 6 percent requiring surgery.1 Electromyography (EMG) and nerve conduction velocity studies (including somatosensory evoked responses and quantitative sensory testing) can evaluate the neurophysiologic (or functional) deficits and must be correlated with the anatomical (or structural) abnormalities as well as the physical examination in patients with suspected cervical radiculopathy, plexopathy or entrapments neuropathies (including thoracic outlet syndrome). Dennervation changes may occur 10-21 days following an acute injury. It can be used to assist with prognosis and determination for additional conservative management.

Other diagnostic testing includes thermography (infrared or liquid crystal) which can detect skin temperature changes over affected trigger points, as controlled by the sympathetic fibers. Surface electromyography can record tonic activity of muscles in spasm over a dysfunctional spinal segment. Recently, soft tissue ultrasonography has been used to confirm segmental abnormalities of the facet, periarticular tissue, tendon, myofascial sheaths, muscle or hematoma. The sensitivity and specificity of these tests has not been fully evaluated, and abnormalities are usually interpreted by asymmetrical responses.

Clinical Manifestations

Cephalagia or headaches can occur as referral patterns from cervical spine injuries with myofascial pain, craniofacial dysfunction (muscles affecting the temporomandibular joint (TMJ)), cervical facet syndromes, upper cervical radiculopathy, post concussion syndrome, vascular (migraines), stress/muscle tension or mixed headaches.2

Myofascial pain is probably the most common reason for post-traumatic neck pain and headaches. Myofascial pain may mimic cervical radiculopathy or thoracic outlet syndrome. Myofascial pain syndromes are commonly found in whiplash injuries. They consist of active trigger points, or regions of soft tissue in which palpation or needling elicits a characteristic referral pattern of pain or sensory disturbance. On examination, one may palpate a taut band, fibrositic nodule, ropiness, with a twitch or jump response associated with tissue texture abnormalities including a hyperemic (histamine) response resulting in impaired flexibility, strength and endurance of the local segment. It is hypothesized that the pathophysiology of trigger points is an abnormality in energy metabolism resulting in tonic activity of muscle spindle (intrafusal) fibers or related to vasomotor instability involving the control of blood supply to the muscle resulting in an accumulation of metabolic waste products, thereby inducing pain. Latent trigger points are regions of localized myofascial tenderness, which can later be activated. Myofascial pain can occur concurrently with other medical and neuro-musculoskeletal disorders, and may be perpetuated and activated by medical (hormonal), musculoskeletal (overload, imbalance or posture), nutritional or emotional factors. Activity, sleep disturbance, stresses, barometric and hormonal variation can modulate it. There is controversy as to whether the diagnosis of a patient with generalized benign soft tissue pain following trauma is an activation of the pre-existing, but latent, fibromyalgia or represents multiple traumatic strains with superimposed myofascial pain.8,9

Posterior headaches may be a result of trapezius and suboccipital trigger points. The SCM muscle has been described by the late Dr. Travell as being “amazingly complex,” and can account for a variety of symptoms including dizziness, tinnitus, dysphagia and visual disturbances, and is presumably related to autonomic referral patterns, as well as frontal and temporal headaches, with facial and jaw pain. Some patients also complain of a sensation of swelling which is probably related to vascular congestion following the hyperextension phase of their injury. Often, myofascial pain of the neck and face is perpetuated by stress, resulting in overlap with muscle tension headaches.9

Post concussion syndrome is a constellation of symptoms following minor head injury including throbbing headaches, nausea, vomiting, dizziness, photophobia, blurry vision, impaired memory, attention or concentration, irritability, insomnia, anxiety and depression, and rarely, seizures. Frequently, in whiplash injuries, there is no overt head trauma or convincing morphologic damage appreciated by brain MRI. In some instances the patient may not perceive that he had a coup/countercoup injury to the brain resulting in a transient and reversible neurophysiological dysfunction. Sophisticated EEG analysis and psychometric testing can sometimes objectify these subtle deficits. For unknown reasons, recovery can vary significantly. It is generally felt that a post concussion headache is due to vascular causes (migraines) in combination with neural transmitter imbalances, particularly involving the serotonin and norepinephrine systems.2

The cognitive deficits following whiplash include memory and concentration problems. Language problems are usually of short duration, and may include word-finding difficulties, stuttering and dyslexic sequence errors, with a global inability to express elaborate thoughts, and a longer latency for responses. Recently, studies have documented disturbances in oculomotor function resulting in slowing of responses in both a reaction time test and ocular motility testing of horizontal saccadic eye movements. These findings have been associated with memory and language deficits and may occur in those individuals without visual difficulties. The mechanism for a visual disturbance following neck injury may be related to the ciliospinal (sympathetic) reflex, in which a noxious stimulus to the face and neck results in pupillary dilatation. Often, patients who present with dizziness have an abnormal rotatory electronystagmogram (found in 54 to 67 percent), and occasionally they may have abnormal caloric testing. This may be related to alterations in cervical afferent proprioceptive fibers of the facet joints and cervical musculature resulting in cervical vertigo. There may also be injuries to the inner ear, resulting in vestibular abnormalities. The generalized weakness experienced by many patients may be a result of reflex inhibition of the spinocortical motor system.2

TMJ dysfunction can occur during hyperextension when the maxilla rotates away from the mandible resulting in the mouth being flung open, injuring the jaw complex. These individuals may present with similar symptoms as post concussion syndrome. A head forward posture, often seen following whiplash, also changes the biomechanics of the jaw resulting in the increased susceptibility for pain and dysfunction. The symptoms may include pain with chewing and bruxism. The patient may have restricted and asymmetric mouth opening with crepitation. A patient with preexisting TMJ dysfunction is at significant risk for the recurrence of this syndrome following a car accident. The muscles of mastication are frequently affected and can respond to myofascial techniques. Additional diagnostic evaluation may include panorex x-rays, MRI, arthrography, ultrasonography and phonosonography. Sometimes, there is disruption of the cartilage (meniscus) and ligaments, which may require formal evaluation by an oral surgeon or dentist. It is highly recommended that the patient receive conservative management including dietary restrictions (dental soft diet and avoidance of chewing gum), medications, exercises, physical therapy, injections and a bite bar appliance, since surgical outcomes have been sub-optimal.2

Upper cervical radiculopathies may result in headaches. Lower cervical radiculopathies may result in referral to the shoulder and upper extremity in a myotomal, scerotomal, or dermatomal pattern. Other causes of paresthesias of the hands, particularly the ulnar region may be related to thoracic outlet syndrome, resulting in neurogenic, arterial or venous symptoms. This may be due to a cervical rib or fibrous bands, hypertonicity of the scalene or pectorals muscles, or in combination, which can be activated following trauma. Provocative noninvasive vascular studies may be helpful in evaluating vascular thoracic outlet syndromes. Occasionally, a traumatic brachial plexopathy can occur, particularly if there is shoulder trauma. Complex Regional Pain Syndromes (reflex sympathetic dystrophy) may also occur, often associated with nerve injuries, and may be diagnosed with a three phase bone scan, thermography, and the patient’s response to stellate ganglion blocks.10

Shoulder and thoracic strain with rib cage dysfunction may also occur as a result of direct trauma, or indirectly from torquing of the torso against the shoulder harness. Often, there is a myofascial component, but shoulder injuries may also cause a rotator cuff syndrome with impingement, acromio-clavicular sprain and pericapsulitis.11 It the authors’ experience that shoulder problems respond slower to conservative management than other musculoskeletal sprain/ strains. Diagnostic testing includes weighted shoulder x-rays to evaluate acromio-clavicular dislocation or MRI for other problems.

Post-traumatic carpel tunnel syndrome may occur from wrist hyperextension after grasping the steering wheel, and must be differentiated from cervical radiculopathy by electrodiagnostic testing.

Prognosis

Most patients should be reassured that the prognosis for recovery following whiplash injuries is very good, though 66% may continue to experience symptoms 6 months following an injury, and 45% can have permanent residual symptoms. Many patients may have complete resolution of their symptoms, yet may have residual restrictions in flexibility, muscular imbalance, and segmental dysfunction of the vertebrae with susceptibility for recurring symptoms, and are predisposed for prolonged recuperation following subsequent injuries. Often, these are older patients, and have pre-existing degenerative changes, including poor posture and deconditioning. Although spontaneous healing of soft tissues occurs within six to eight weeks, injuries to the disk, vertebrae and facet joints can take longer.1,2

Conservative Treatment

The treatment for acute whiplash usually involves the application of ice for the first 48 hours, with relative rest, followed by moist heat. A soft cervical collar, with the closure in front, may be used for symptomatic relief of patients with guarded and restricted motions. It should be discontinued after two weeks because of additional weakness of the cervical muscles and perpetuation of a head forward posture. If the patient’s restricted motions significantly interfere with neck rotation, then it is advisable that he refrain from driving.3

Anti-inflammatory medications and analgesics, with judicious use of narcotics have been prescribed. For those patients with chronic pain, long acting forms of analgesics and anti-inflammatory medications are recommended on a time contingent basis to improve compliance, minimize the euphoric effect of narcotics, minimize pain behavior and allow a better modulation of pain management. Muscle relaxants should generally be used at night to assist with sleep restoration, and work through a central mechanism. Other medications that may be prescribed include low dose antidepressants for sleep restoration, sedating medications to reduce muscle spasm and sleep, and selected medications to control headaches (i.e. Midrin, Phrenilin, and Fiorinal). Antihistamines may be used in myofascial pain syndromes and to assist with sleep. For subacute and chronic pain, antidepressants or anti-anxiety medications (long acting benzodiazepines or buspirone) may be used. For headache prophylaxis, anticonvulsants (especially valproate), beta-blockers, calcium channel blockers, antidepressants and olanzapine may be used. For radicular pain with dysesthesias, considerations should be made for prescribing anticonvulsants (especially gabipentin), and this neurogenic pain tends to be less responsive to narcotics. Capsaicin cream may be used over regions of localized pain. Recently, topical skin emollients have been used including cyclobenzaprine, anti-inflammatory medications, doxepin, lidocaine (also available in patch) or ketamine. Sympathetic blockers or clonidine or tazinidine may be used for complex regional pain syndromes or to improve their tolerance to chronic opioids. Steroids may be used for acute myelopathy, radiculopathy or facet syndromes.7

A decision to initiate a formal treatment program is based upon how the patient’s symptoms impact on their functioning, examination abnormalities involving the musculoskeletal and neurologic systems, and their reliance on habituating medications. Physical medicine modalities, including superficial and deep heat, electrical simulation, traction, massage, myofascial releases, mobilization, manipulation, traction, and therapeutic exercises have been utilized for these patients. Treatment is often performed by physical therapists or their assistants, but chiropractors may also be involved.7 Complementary and alternative medicine approaches include massage therapy, acupuncture (with a success rate ranging from 75 to 91 percent),2 biofeedback, magnets and nutritional/herbal supplements. All treatments should incorporate patient education and home exercises. It is important that the patient be empowered to take an active role in his/her treatment with the goal of restoring function as quickly as possible. The goal of treatment is for early mobilization and return to their pre-injury level of activity.7

Myofascial injections or dry needling are adjunctive to physical medicine modalities in the treatment of myofascial pain syndromes. They consist of dry needling, injecting local anesthetic, saline, water, steroids, or serapin (an herb) into the trigger point either in the muscle, tendon, ligament, subcutaneous or scar (which can mechanically disrupt this region). The injections may also minimize the afferent sensory fiber impulses that transmit pain. The main purpose of treatment is to deactivate the trigger point so as to allow improvement in the local flexibility and function with concomitant reduction in pain. Initially, the trigger point injections are for diagnostic purposes to determine the patient’s response, both physically and emotionally. Prior to injections, the patient should be counseled as to appropriate strategies to tolerate the injection, and this allows the physician to assess the patient’s pain coping response. Subsequently, they can be used therapeutically; that is the patient’s response exceeds the predicted duration of the medication injected. Side effects may include bleeding, pneumothorax, allergic reactions and post injection soreness; the latter reaction can be treated with antihistamines. A peripheral nerve block to the greater occipital nerve, theoretically as a result of posttraumatic entrapment, may overlap with the suboccipital trigger point.8,9

The prevalence of cervical facet dysfunction following motor vehicle accidents is 25 to 65 percent, most commonly affecting the C2-3 and C5-6 regions. The patients may present with occipetal headaches and referred pain into the neck, shoulder. Cervical medial branch of the posterior ramus nerve blocks are performed at several levels (because of the overlapping innervation of the posterior sensory rami to the zygoapophyseal joint complex) with local anesthetic (and perhaps steroids), under fluoroscopic guidance by an experienced physician. Direct injections into the facet joints are to be discouraged to avoid direct trauma to the joint. Studies suggest this procedure can improve appropriate patients with chronic neck pain and should be performed in conjunction with a multidisciplinary approach to the patient. If two or three series of blocks are helpful at least temporarily, then considerations should be made for radio-frequency neurolysis. Side effects may include improper needle placement resulting in reversible neurologic deficits as a result of nerve or artery injuries.1

A cervical discogram may be used to diagnose the cervical disk as a generator of pain even without radicular symptoms or neurologic findings. It carries similar procedural risks, and is considered to be abnormal if it: provokes symptoms following a saline injection, improves their symptoms following a local anesthetic injection, radio-opaque dye reveals disk incompetence, or previously performed facet injections at the same level have been found to be ineffective. A positive discogram should be interpreted cautiously in determining a patient’s candidacy for cervical fusion.1

Vertebral adjustments, as performed by a chiropractor, can be helpful in improving subluxations, or spinal manipulations, as performed by an osteopath, can be helpful in improving segmental dysfunction, particularly during the acute phase. It usually involves a rotational and lateral thrust of low amplitude and high velocity performed by a skillful clinician that is adept at diagnosing and manipulating specific spinal segments. Initially, less forceful mobilization, with muscle energy techniques, allows improved relaxation of the soft tissues. Additional treatments may involve the thoracic spine, rib cage, shoulders and jaw. In older patients with significant osteoarthritis or osteoporosis, an activator (a spring-loaded tool) may be used for gentle manipulation. Studies indicate that manipulation is more effective for treatment of subacute nonspecific neck pain, resulting in improved flexibility. Contraindications include spinal instability, fractures, malignancy, and large disk herniations with significant neurologic findings.2 Mobilizations are another form of manual medicine, which employ low velocity, high amplitude maneuvers to improve segmental joint dysfunction. This may be performed by a physical therapist that has specific training and may include craniosacral mobilization.12

Physical medicine modalities, including therapeutic cold, heat (superficial and deep), and electrotherapy can be helpful in treating the soft tissue components of the patient’s symptoms. This allows a relaxation of these tissues to facilitate a therapeutic stretch and rebalancing of the muscle tendon complex followed by myofascial release or massage techniques. Stretching of the shoulder (subscapularis) may enhance the patient’s response to cervical spine stretching. Techniques may also include strain/counterstrain to help reset the agonist/ antagonist neural control of the involved muscular segments. Passive modalities should only be used on a limited basis and then incorporated into a comprehensive program including active exercise. The dosing and quality of physical therapy is important in determining the patient’s response. Often, daily treatment may be required for rapid facilitation of functional recovery, particularly if the patient is released from work, and to assess the patient’s compliance and motivation for wellness. Contraindications to certain modalities include pregnancy, malignancy, pacemakers, open wounds, and skin sensitivity to the modalities or emollients.7,11,13

Cervical traction may be used to distract the cervical vertebrae to improve facet alignment, and to stretch the cervical paraspinal musculature. Saunders traction minimizes the stress on the jaw and is useful for TMJ dysfunction. Home static cervical traction may be used in reliable patients who present with significant cervical facet dysfunction or disk derangement, particularly if there is restrictions in neck extension. In those patients who are acute and fragile, manual cervical traction may be helpful. Contraindications include cervical spine fractures, instability and neoplasms.7,13

Therapeutic exercise is the hallmark of treatment for cervical strain/sprain. During the acute phases, isometric exercises will prevent deconditioning without stressing the joints of the neck. Postural exercises, including cervical gliding and instruction in proper body mechanics, is important in minimizing a head forward posture causing increased tone of the sternocleidomastoid muscle. Other exercises include therapeutic static stretching, which can be enhanced by exhalation, particularly of the trapezius, scalene and pectoralis. Once the patient regains sufficient flexibility, then isotonic followed by isokinetic strengthening may be performed using manual resistance, cuff weights, or exercise equipment. Low impact aerobic conditioning including walking, and advancing to bicycling, swimming, rowing or cardioglide should be initiated early on in a rehabilitation program. Home exercises and simple modalities (hot or cold pack, cervical roll or pillow and TENS) are recommended to minimize the risk of recurring pain and disability. Education is important for reassurance and to reinforce the importance of proper posture, body mechanics and compliance with home exercises.13

Psychological Aspects

Psychosocial counseling can be a useful adjunct in those patients who require stress management, pain coping strategies and relaxation training (including surface electromyographic biofeedback). Often, there is fear associated with physical activities (kinesiophobia) because of the patient’s perception that they will be damaging themselves when performing them — even if they are not strenuous. They often require reassurance that their condition is benign in nature, their pain does not represent additional tissue damage, and they can safely return to their pre-injury level of activities, even if it may temporarily aggravate their symptoms. In many patients, there is an associated fear of driving, which responds well to desensitization techniques in a non-pressured environment. Patients may experience an adjustment reaction with anxious or depressed features, or a post-traumatic stress disorder precipitated by this injury. Often, these patients have had a traumatic event in the past, which is re-lived following their injury, resulting in a heightened level of distress. The patient must be informed about the recurring nature of pain, and appropriate ways of treating this. Counseling can also assist the patient in problem-solving relative to how the injury has impacted on the patient’s lifestyle including finances, transportation, work and relationships. Often, the psychological treatment of chronic neck pain relies on cognitive behavioral training based upon cognitive and operant conditioning theories. Scheduling of treatments including medications ideally should be on a time contingent basis. A ‘significant other’ may assist in reinforcing appropriate wellness, compliance with treatment recommendations, including activities, home exercises and minimizing disability-oriented behavior.7 One study reported success in returning to a normal life style — including work — occurred in 75 percent of chronic neck sufferers, following a four-month treatment program by an experienced team.1 Vocational rehabilitation for job placement or retraining may be necessary in those individuals who require permanent limitations in their activities.

Psychometric testing may help the mental health worker in determining the personality style of the patient, his intelligence, how pain impacts on the patient’s function, and the presence of depression or anxiety, to allow a more efficient means of improving psychosocial status. These tests may suggest whether psychotropic medications should be considered in the treatment program. Recent studies of individuals with whiplash have shown that deficiencies in the patient’s perception of well being, increased nervousness, irritability and depression, as well as their psychological symptoms are often dependent on the persistence of somatic symptoms.2

Medico-legal Aspects and Disability Assessment

There is controversy as to whether the medico-legal aspects of whiplash injury contribute to the patient’s recovery. Several studies have concluded that patients show significant improvement with treatment despite ongoing litigation. If there is a psychogenic component, why do many patients who sustained multiple traumas only complain of residual neck pain? There is currently no evidence to suggest that pre-existing personality traits or psychiatric problems contribute to their ongoing somatic symptoms following whiplash injuries.2 However, it is the authors’ opinion that patients with work- related motor vehicle injuries tend to have a longer recovery. In many instances, a patient with residual symptoms will continue to experience neck pain despite settlement of his legal case. Rarely are there malingerers. Certainly, there are patients who tend to magnify their symptoms out of proportion to their mechanism of trauma or physical examination findings. These patients require validation of their injury early on in conjunction with a formal and well-structured comprehensive interdisciplinary treatment program that demands compliance and self-reliance. Identification of secondary gain motives, including financial disincentives (such as wage replacement), family stressors, work satisfaction and medico-legal issues, are paramount in coordinating a treatment plan. The most challenging patient is the one with functional overlay who declines counseling. This is particularly problematic when the patient has an abnormality on diagnostic testing which the patient focuses on, but does not correlate well with symptoms and examination. Strategies to improve the patient’s response may include the enlistment of his ‘significant other,’ or utilizing a mental health counselor in a supportive and non-threatening fashion as his advocate. Confrontation often is ineffective.7

Patients with soft tissue injuries feel that their credibility is at stake when the insurance company discredits their symptoms and denies time loss compensation and treatment benefits via a “purchased” independent medical evaluation. On the other hand, there have also been many documented cases of insurance fraud, and insurance companies frequently perform undercover surveillance on patients to document inconsistencies in function and range of motion. It is unfortunate that negative outcomes can occur in an adversarial system with delays in compensation, particularly in a patient that experiences anger, victimization, and vindication of innocence — especially if he had prior litiginous injuries.7

The clinician must carefully document patient symptoms in an attempt to objectify their findings through subtleties of tightness and weakness, as well as consistency of their symptoms and regions of trigger points and segmental dysfunction. The patient’s response to treatment must be recorded, including improvements in pain rating scale, overall tolerance of activities, and quantified by changes in flexibility, strength and endurance as documented by a functional capacity evaluation, as well as functional outcome scales. Videography can be helpful to document the patient’s initial evaluation and serially monitor their progress and depicting their treatments (such as trigger point injections).7

The practitioner must be able to causally relate the patient’s initial and current symptoms to their injury, determine that the care provided was medically necessary, and that the charges were fair and reasonable. Anticipation of endpoints of treatment should be addressed early on with the patient, so that he can prepare himself for the possibility of residual symptoms and subsequent medical care. In certain patients, the treatment costs are disproportionately high. This may make it difficult to financially resolve their case, and the patient may require additional counseling relative to the financial implications of continuing treatment, testing and disability. The physician may need to speak directly to the patient’s attorney to express his opinion regarding the patient’s credibility, diagnosis, prognosis, treatment recommendations, residual disability and issues of liability in preparation for courtroom testimony.

Conclusion

Whiplash can occur in many crash situations, and is caused by several different mechanisms. It is difficult to make specific, uniformly agreed-upon diagnoses of the pain generators in many cases of whiplash. Fortunately, for most cases, this is not important, since many patients will improve (whether the patient is actually rendered pain-free or not). Continued research is necessary to further evaluate the efficacy of individual interventions. However, one would not expect any specific single modality in the management of a multi-modal disease process such as post-traumatic musculoligamentous strain/ sprain to the neck. Early intervention, with multi-modality treatment and interdisciplinary care, can effectively treat acute pain and dysfunction appropriately, will likely result in optimizing outcomes by preventing significant residual disability, and possibly prevent chronic pain. Additional research will also be needed to design safer motor vehicles so as to minimize the risk of all injuries following collisions.

Last updated on: November 1, 2012
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