Cervical Sprain and Strain Follow-up

Updated: Oct 05, 2017
  • Author: Oregon K Hunter, Jr, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
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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.

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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
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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.

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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.

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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.

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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, disc, 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. [83]

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. [38] 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. [36]

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. [84]

The greatest risk for long-term symptoms occurs in patients with point tenderness and limited ROM. [85]

In a study by Gun and colleagues, bodily pain scores and role emotional scores of the 36-Item Short Form Survey (SF-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. [86]

A Japanese study, by Oka et al, found that, among persons involved in a traffic collision, patients with whiplash-associated disorder suffering from intractable neck pain tended to have worse psychological test scores than did controls suffering from minor neck pain successfully treated within 3 months. The two groups differed significantly with regard to their scores on the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale, the SF-36 mental health component summary, and the EuroQol-5 dimension questionnaire (with this last used to assess general quality of life). [87]

Similarly, a study by Elphinston et al found that reductions in fear of movement and reinjury and pain catastrophizing were linked to a rising expectation of recovery in patients. [88]

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. [89]

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. [90] 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.

Sterling et al evaluated a prognostic model for chronic whiplash injury-related disability that used the Neck Disability Index as an outcome measure, and age, decreased cold pain thresholds and peripheral vasoconstriction (indices of central sensitization), decreased cervical range of motion, post-traumatic stress symptoms, and initial disability as predictors. They found that their model demonstrated good accuracy for predicting which patients would have moderate to severe disability one year after injury. [91]

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. [92]

Associated comorbidities

Petterson and colleagues proposed a possible association between whiplash injury and cervical disc disease, suggesting that trauma to the cervical spine may accelerate normal age-related deterioration of the discs. [34]

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. [93]

In another study, Radanov and co-investigators examined patients with injury-related symptoms at 2 years. [93] 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. [94] 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. [95]

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. [96]

Depressive symptomatology after whiplash is common, occurs early, and often persists or becomes recurrent. [97]

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. [98]

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. [99]

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. [100, 101]

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. [102] See also Medical/Legal Pitfalls.

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Patient Education

Patient education in self-care is important in preventing dependence on health-care providers, as well as in preventing excessive disability.

A physical therapist can teach patients with chronic cervical strains how to use proper postural and body mechanics.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center and Osteoporosis Center. Also, see eMedicineHealth's patient education articles Neck Strain, Shoulder and Neck Pain, Sprains and Strains, and Whiplash.

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