Neck Pain and Whiplash

Neck Pain and WhiplashIntroduction Goals of Therapy Neck Pain: Acute Phase to 30 Days Investigations - pdf za darmo

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Neck Pain and Whiplash

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Neck Pain and Whiplash Eldon Tunks, MD, FRCPC Paul Stacey, MD, MSc Date of Revision: February 2014


Neck pain is one of the most common conditions seen in primary practice,1 and is one of the chief presenting symptoms of whiplash, resulting from motor vehicle collisions. Whiplash is defined as a hyperextension-hyperflexion mechanism of energy transfer to the neck which may cause bone or soft-tissue injuries.2 This chapter will discuss the management of acute neck pain, including the common presentation of whiplash, in addition to the management of general subacute and chronic neck pain.

Goals of Therapy Acute Phase

Reduce distress

Identify patients in need of urgent surgical intervention 1–4 Weeks Promote therapy to restore function

Return to normal activities as soon as possible Subacute Period (4–12 Weeks) Interrupt progress to chronicity

Promote active therapy while encouraging return to work Chronic Pain (6 Months or More) Multimodal therapy aimed at management of chronic pain/disability, with emphasis on restoring function and independence

Neck Pain: Acute Phase to 30 Days Investigations

Acute Phase (Days 1–7) History and physical examination. Assess for “red flags” (Table 1); based on history, physical examination and laboratory findings, classify according to Whiplash-Associated Disorders (WAD) criteria (Table 2, Figure 1)2 or according to Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Table 3).3 Decision to x-ray is based on history of severe trauma, impaired consciousness and neurologic signs and symptoms. However, neurologic findings may not be present or prominent with cervical fracture, so clinical judgment/experience and imaging are necessary when fracture is suspected.2

When neurologic injury or cervical spine injury is a concern, please refer to the Canadian C-Spine Rule (Figure 2) and seek expert guidance.

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Table 1: Possible Red Flags Associated with Neck Pain History of severe trauma Impaired consciousness

Loss of reflexes

Sensory or motor deficits

Table 2: Whiplash-Associated Disorders (WAD) Classification

Lower body sensory changes

Loss of bowel or bladder function



neck pain, stiffness or tenderness, but no physical signs/limitations


pain and tenderness and reduced range


pain and neurologic signs; sensory or motor or reflex changes without fracture/instability


fracture or dislocation a,3

Table 3: Bone and Joint Decade 2000-2010 Classification Grade I

neck pain/associated disorders without indication of major structural pathology, and either minor interference or no interference with activities of daily living (ADL)

Grade II

no indication of major pathology, but major interference with ADL

Grade III

no indication of major pathology, but having neurologic signs (abnormal reflexes, weakness, sensory deficits)

Grade IV

signs/symptoms of major structural pathology (may include fracture, vertebral dislocation, spinal cord injury, infection, neoplasm, systemic inflammatory disease)

This is applicable to all neck pain, not only WAD. Reference also recommends a separate dimension distinguishing presence of claim for reimbursement, or wage replacement, long-term disability, permanent disability or punitive damage.


Therapeutic Choices Nonpharmacologic Choices

WAD-I to WAD-III (Bone and Joint Decade classification Grades I-III): Provide symptomatic relief as indicated, reassure and counsel to resume normal activity as soon as possible. Avoid immobilization or passive therapy, except in the case of acute cervical radiculopathy (see WAD-III below).2 Bone and Joint Decade classification Grade I or II neck pain: Patient education combined with urgent care improves acute whiplash outcome. However, educational interventions by themselves (advice to stay active, neck school, relaxation) have demonstrated only very weak efficacy in pain relief or functional improvement.4 Collars and high health-care utilization may be associated with delayed recovery.5 WAD-III (Bone and Joint Decade classification Grade III): When dealing with acute cervical radiculopathy, there is evidence of benefit for treatment with rest and a semi-hard collar for 3–6 weeks.6 WAD-IV (Bone and Joint Decade classification Grade IV): Urgent referral and surgical management.2,6 Scientific evidence regarding initial management of neck pain and whiplash is limited and of poor quality.7 However, there is considerable agreement among experts that patients should be advised to return to usual activity as soon

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as tolerated, avoiding collars, bedrest or immobilization, and limiting or avoiding work absence.8,9 If progress is not occurring as expected by the end of the first month, consider the possibility of psychosocial barriers or complications. Active exercise combined with psychosocial intervention results in reduced pain in the short term and accelerates return to work.2 However, early multidisciplinary treatment (<4 weeks postinjury) has not been shown to be more effective than usual care.10

Pharmacologic Choices

Pharmacologic options to treat neck pain and whiplash are presented in Low Back Pain, Table 3. While NSAIDs are more effective for symptom relief than placebo during the first month of back pain,11 there is a paucity of studies to evaluate efficacy of NSAIDs in acute neck pain and whiplash, even though in practice they are often recommended.12 In back pain studies, there is no evidence that any one NSAID is more effective for reducing pain.11 Consider individual patient contraindications and the risks associated with use of NSAIDs, such as history of GI or cardiovascular disease. Acetaminophen, tramadol, codeine or muscle relaxants are appropriate alternatives in the acute phase of neck pain. A single high-quality study reported that iv methylprednisolone for acute whiplash of less than 8 hours' duration led to reduced pain at 1 week and reduced sick leave but not pain at 6 months.13 Risks of high-dose corticosteroid therapy include immunosuppression and pulmonary infection.14 This treatment option is not recommended until further studies become available.

Neck Pain: Subacute Period (4–12 Weeks) Investigations

Order plain radiographs for neck pain lasting more than a few weeks, or more detailed studies if there is nerve root or spinal cord involvement or history of such injury.15 For those not making progress in function, or suffering unexpected prolongation of pain, review to identify potential psychological risk factors (Table 4). By this time, combined therapy is preferable: psychosocial, patient education and active exercise. Promote work re-entry, with modifications if appropriate, if there has been delay. Table 4: Identification of Psychological Risk Factors


Obvious psychological distress

Severe pain beyond what is expected

History of prior significant pain recurrences

Higher than expected functional impairment Unexplained widespread pain

Pain and limitation not consistent with objective findings

Therapeutic Choices Nonpharmacologic Choices

There is evidence of efficacy of exercise over passive therapy. There is limited evidence for taking breaks during sedentary work. Moderate quality evidence shows moderate pain relief and improved function for combined cervical, scapulothoracic stretching and strengthening for chronic neck pain.18 Patients may feel more benefit from

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such therapies. Combining exercise with passive therapies may also be beneficial. For example, combining psychoeducation with a few sessions of active physiotherapy is effective for reducing disability in the subacute period.19 Evidence favours supervised exercise with or without manual (mobilization) therapy, although there is limited evidence that exercise combined with manual therapy is efficacious for subacute and chronic neck pain.20,21 There is weak evidence that advice and exercise is better than advice alone in the short term for subacute whiplash symptoms.5 Although there is a lack of quality evidence for the efficacy of treatment with only passive and palliative physical therapy modalities or medications for symptom relief, they may be used in conjunction with active measures to promote patient comfort and adherence to the active treatments. There is limited and low-quality evidence for manual therapy for subacute and chronic neck pain.2,20 The role of manual therapies, e.g., manipulation or mobilization of the spine, is still controversial, partly due to a very small but real risk of vertebrobasilar stroke after manipulation.22,23 Manipulation or mobilization should be performed only by an expert therapist with certified skills in manual therapy and with appropriate clinical screening to exclude patients with risk factors for complications. There is evidence for massage added to manual therapy,5 but evidence for massage is of poor quality.24 There is inconsistent evidence that acupuncture is associated with better short-term and long-term outcome in subacute or chronic neck pain, compared with sham acupuncture or massage.5 For neck pain Grade I and II, patient education focusing on self-efficacy, combined with usual medical care, appears promising. Weak and limited evidence exists that magnetic therapy or transcutaneous electrical nerve stimulation (TENS) is more effective in the short term than alternatives.25

Pharmacologic Choices

Pharmacologic options to treat neck pain and whiplash are presented in Low Back Pain, Table 3. There is limited evidence supporting ef...

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