eMedicine Specialties > Physical Medicine and Rehabilitation > Cervical Spine Disorders

Cervical Sprain and Strain: Follow-up

Author: Oregon K Hunter Jr, MD, Physiatrist, Southeastern Rehabilitation Medicine, SIMED
Coauthor(s): Michael D Freeman, PhD, MPH, DC, Clinical Associate Professor of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health Sciences University; Adjunct Associate Professor of Forensic Medicine and Epidemiology, Institute of Forensic Medicine, Faculty of Health Sciences at Aarhus University, Denmark
Contributor Information and Disclosures

Updated: Jul 15, 2009

Follow-up

Further Outpatient Care

  • Acute medical follow-up is performed at 1- to 2-week intervals.
  • Subacute medical follow-up is performed at 2- to 4-week intervals.
  • Long-term medical follow-up is performed at 1- to 12-month intervals
    • The type of medication prescribed for pain may influence the frequency of follow-up visits. For example, patients taking schedule II opiates require monthly follow-up visits.

Inpatient & Outpatient Medications

  • Chronic cervical strain management requires an individually tailored medication regimen, which could require a combination of the following:
    • Analgesics
      • Acetaminophen (Tylenol)
      • Opiates (Consider applicable medical practice guidelines for their appropriate use in chronic benign pain syndromes.)
    • Muscle relaxants
      • Soma
      • Robaxin
      • Skelaxin
      • Flexeril
      • Zanaflex
      • Parafon-Forte
    • Low doses of sleep disturbance aids
      • Elavil
      • Pamelor
      • Desyrel

Transfer

  • Neuromusculoskeletal specialists, such as physiatrists, often perform follow-up evaluations in patients with cervical sprains or strains.
  • Patients may also be followed up by orthopedists, neurologists, neurosurgeons, rheumatologists, or family practitioners.

Deterrence

  • Most cervical strains are a by-product of our industrial society and the primary means of transportation, the motor vehicle.
  • Motor vehicle safety appears to be a primary focus for deterrence.

Complications

  • Chronic pain syndrome may develop in certain individuals.
  • This syndrome may be characterized by excessive disability, dependence, prescription drug use, depression, and dramatization of pain behavior.
  • Referral to a chronic pain specialist may be indicated.

Prognosis

  • Short-term recovery
    • Many patients improve within 8 weeks, although complete resolution in this period may not be common. If pain persists for longer than 3 months, severe ligamentous, disk, or associated facet injury is suggested. Recovery after whiplash occurs mostly in the first 2-3 months after the accident. After that, recovery slows dramatically, with no further change in symptoms after 2 years.
    • At 6 months after the injury, 20-70% of patients with neck injury due to an automobile accident still experience pain.
  • Long-term recovery
    • Dreyer and Boden examined patients 10 years after the onset of neck pain and found that 79% had improved, 43% were pain-free, and 32% had persistent, moderate to severe pain.36 In a group of patients with significant symptoms at 10 years after whiplash injury, Barnsley and colleagues found that everyone had degenerative changes on radiographs, at a significantly higher rate than that of a control group.34
    • Whiplash patients with ongoing moderate or severe symptoms at 2-3 years continued to show decreased ROM, increased electromyographic activity during craniocervical flexion, and sensory hypersensitivity. They also showed elevated levels of psychological distress compared with those of patients with milder symptoms or with individuals who had recovered.76
    • The greatest risk for long-term symptoms occurs in patients with point tenderness and limited ROM.77
  • In a study by Gun and colleagues, bodily pain scores and role emotional scores of the Short Form-36 health questionnaire were consistently and significantly positively associated with improved outcomes. Consulting a lawyer was associated with a decreased likelihood of claim settlement and an increased likelihood that the patient would still be receiving treatment after 1 year. However, such consultation was not significantly associated with a return to work. The degree of damage to the vehicle was not a predictor of outcome.78
  • According to a study by Hendriks et al, factors related to poor recovery from whiplash-associated disorder include female sex, a low level of education, high initial neck pain, severe disability, and high levels of somatization and sleep difficulties. Neck pain intensity and work disability were the most consistent predictors for poor recovery.79
  • Similar results were found by Walton et al in a study investigating factors affecting prognosis in patients who have sustained whiplash injury in a motor vehicle accident.80 Their meta-analysis of 3,193 patients found 9 significant predictors: absence of postsecondary education, female sex, history of neck pain, neck pain intensity of more than 55/100, presence of neck pain at baseline, presence of headache at baseline, catastrophizing, whiplash-associated disorder grade 2 or 3, and failure to use a seat belt at the time of collision. Of those factors, 4 were robust to publication bias: neck pain intensity, whiplash-associated disorder grade, headache, and absence of postsecondary education.
  • Use of a "fear-avoidance model" may prove effective for understanding the development of persistent complaints following an acute whiplash injury. It is postulated that the injured patient is caught in a downward spiral of increasing avoidance, disability, and pain.81
  • Associated comorbidities
    • Petterson and colleagues proposed a possible association between whiplash injury and cervical disk disease, suggesting that trauma to the cervical spine may accelerate normal age-related deterioration of the disks.32
    • One study showed that increasing age, injury-related cognitive impairment, and severity of the initial neck pain were predictive of persistent symptoms at 6 months.82
    • In another study, Radanov and co-investigators examined patients with injury-related symptoms at 2 years.82 Compared with other patients, symptomatic patients were older and had an increased incidence of rotated or inclined head position at the time of impact, an increased prevalence of pretraumatic headache, and an increased intensity of initial neck pain and headache. Symptomatic patients also had more symptoms (including those of radicular deficit), higher average scores on a multiple-symptom analysis, and more degenerative signs (osteoarthritis) on radiographs.
    • Disabling neck pain is associated with other comorbidities (headache, cardiovascular problems, digestive problems, low back pain) that negatively affect the patient's health. The prevalence of neck pain and disability is increased in individuals with a lifetime history of neck injury who are involved in a motor vehicle collision.83 Low back pain is a common injury with prolonged recovery. Biopsychosocial factors, such as the type of compensation system that exists, affect the incidence and prognosis.84
    • Chronic psychiatric disease is more common in patients with chronic symptoms (chronic whiplash-associated disorder) than in others. The dominant psychiatric diagnosis before and after the injury is depression. Psychiatric morbidity may be a patient-related risk factor for chronic symptoms after a whiplash injury and seems to be associated with psychiatric vulnerability.85
    • Depressive symptomatology after whiplash is common, occurs early, and often persists or becomes recurrent.86
    • The incidence of widespread pain disorders increases after cervical spinal injury. In a study of 161 cases of traumatic injury, fibromyalgia syndrome was 13 times more frequent after neck injury than after lower-extremity injury.87
    • Chronic whiplash-associated disorders are characterized by mechanical hyperalgesia over the cervical spine and by widespread hypersensitivity to mechanical pressure and thermal stimuli; this finding was independent of state of anxiety and may represent changes in central pain-processing mechanisms.88
    • A study of a large cohort of individuals involved in traffic accidents showed that patients with whiplash-associated disorders may demonstrate symptoms well beyond the neck, including fatigue, dizziness, paresthesias, headaches, spinal pain, nausea, and jaw pain.89
  • Medicolegal considerations - The prognosis of acute whiplash varies according to the population sampled and the insurance/compensation system under which individuals are allowed to claim benefits.90 See also Medical/Legal Pitfalls.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The failure to evaluate completely the integrity and stability of the cervical spine with appropriate imaging studies when indicated by the clinical picture is a pitfall.
  • The failure to document adequately an appropriate neurologic examination to confirm the presence or absence of radiculopathy and/or myelopathy is another pitfall.
  • The term whiplash should generally be avoided when possible when documenting the medical findings in a patient with a cervical strain. Use of the term whiplash to describe cervical strain injuries may implicate political, medicolegal, or emotional connotations, thereby detracting from the clinical reality of cervical strain injuries.
  • Whiplash injury is one of the more frequently disputed conditions in the medical literature. More than $29 billion dollars per year are spent on whiplash injuries and litigation in the US alone.
    • The prognosis of acute whiplash varies according to the population sampled and the insurance and/or compensation system under which individuals are allowed to claim benefits.90
    • Patients may continue to experience neck pain despite the settlement of legal cases. In rare cases, patients can be malingerers. Some patients may tend to magnify their symptoms out of proportion to their mechanism of trauma or the physical examination findings.91
    • The natural history of acute whiplash-type complaints may be more favorable in the Greek medicolegal system, which does not allow financial compensation for low-energy accidents.
    • In Lithuania, where few drivers have car insurance, Schrader and colleagues found that chronic symptoms of late whiplash syndrome were not related more to expectations of disability, family history, and pre-existing symptoms than they were to car accidents.92
  • Freeman determined that the following statements had no epidemiologic or scientific basis, as reported in the literature37 :
    • "Whiplash injuries do not lead to chronic pain."
    • "Rear-impact collisions that do not result in vehicle damage are unlikely to cause injury."
    • "Whiplash trauma is biomechanically comparable to common movements of daily living."
 


More on Cervical Sprain and Strain

Overview: Cervical Sprain and Strain
Differential Diagnoses & Workup: Cervical Sprain and Strain
Treatment & Medication: Cervical Sprain and Strain
Follow-up: Cervical Sprain and Strain
Multimedia: Cervical Sprain and Strain
References
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Further Reading

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Keywords

C-spine sprain, C-spine strain, acceleration/deceleration injury, acceleration-deceleration injury, cervical myofascial pain, cervical soft-tissue pain syndrome, cervical sprain, cervicobrachial strain, chronic cervical sprain, chronic cervical strain, chronic neck sprain, chronic neck strain, extension-flexion injury, extension/flexion injury, flexion-extension injury, flexion/extension injury, hyperflexion-hyperextension injury, hyperflexion/hyperextension injury, neck/shoulder girdle soft-tissue injury, neck sprain, neck strain, regional soft-tissue pain syndrome, WAD, whiplash-associated disorders, whiplash syndrome

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Contributor Information and Disclosures

Author

Oregon K Hunter Jr, MD, Physiatrist, Southeastern Rehabilitation Medicine, SIMED
Oregon K Hunter Jr, MD is a member of the following medical societies: American Academy of Pain Management, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Legal Medicine, American College of Occupational and Environmental Medicine, American Congress of Rehabilitation Medicine, American Medical Association, Florida Medical Association, Florida Society of Physical Medicine and Rehabilitation, International Association for the Study of Pain, International Society of Physical and Rehabilitation Medicine, National Association of Disability Evaluating Professionals, and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michael D Freeman, PhD, MPH, DC, Clinical Associate Professor of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health Sciences University; Adjunct Associate Professor of Forensic Medicine and Epidemiology, Institute of Forensic Medicine, Faculty of Health Sciences at Aarhus University, Denmark
Michael D Freeman, PhD, MPH, DC is a member of the following medical societies: American Academy of Forensic Sciences, American Academy of Pain Management, American College of Epidemiology, Association for the Advancement of Automotive Medicine, North American Spine Society, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology
Disclosure: Allergan pharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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