Rehabilitation Program
Physical Therapy
Early rehabilitation helps to prevent chronic pain and disability. Passive modalities include the application of heat, ice, electrical stimulation, massage, myofascial release, and cervical traction. Passive modalities are often used to decrease pain or inflammation and to facilitate participation in an active rehabilitation program, which often involves stretching and strengthening. Extended use of passive modalities without a more active program is generally inappropriate.
Active treatment refers to therapeutic exercises that are aimed at improving the patient's strength, endurance, flexibility, posture, and body mechanics. The goal is to obtain an independent home program or community fitness program at the conclusion of formal physical therapy. The typical therapy prescription is recommended 3 times per week for 4-8 weeks.
Scientific evidence for the physiotherapeutic management of whiplash is sparse. An early, active strategy is recommended to improve functions, increase activity, and prevent chronicity. [70] In patients with whiplash-associated disorders caused by a motor vehicle collision, treatment with frequently repeated active submaximal movements combined with mechanical diagnosis and therapy is more effective in reducing pain than is a standard program of initial rest, use of a soft collar, and gradual self-mobilization. [71]
In patients with whiplash-associated disorders, active intervention is more effective than standard intervention in reducing pain intensity and sick leave, as well as in retaining/regaining total range of motion (ROM). Appropriately trained healthcare professionals can start and support active intervention, that is, frequently repeated, active cervical rotation, which can be followed, if needed, by assessment and intervention according to the McKenzie protocol. [72] Strength and endurance training for 12 months are effective for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone are less effective than strength training. [73, 74]
Specific neck exercises for the management of chronic neck pain, including active activation of the deep neck muscles and dynamic strengthening, may significantly improve disability scores. [10] Consistent evidence (from 2 randomized, controlled trials) supports mobilization as an effective, noninvasive intervention for acute whiplash-associated disorders. [75, 76]
A study by Treleaven et al suggested that neck-specific exercise led by a physiotherapist, with a behavioral approach included, is more effective in treating dizziness associated with chronic whiplash than either neck-specific physiotherapist-led exercise without a behavioral approach or general physical activity. The study included 140 patients, who were followed up for 12 months. [77]
Using the same types of exercise as in the Treleaven study, Landén et al found that in terms of pain, self-rated functioning and disability, and self-efficacy, in persons with chronic whiplash, neck-specific exercise with or without a behavioral approach was associated with significantly greater improvement than was general physical activity at 1-year follow-up, but not at 2 years. The study included 216 patients. [78]
In examining the costs and consequences of 2 types of intervention after whiplash trauma in automobile crashes, active intervention using physical therapy was found to be less costly and more effective than short-term immobilization using a cervical collar followed by a gradual self-exercise program taught by a leaflet. [79]
Another study questioned the efficacy of therapeutic interventions. The report found that 1 year after whiplash injury, a strategy employing immobilization, "act-as-usual," or mobilization had a similar effect to the other 2 methods in terms of pain prevention, disability, and work capability. [80]
Occupational Therapy
Occupational therapy may be indicated unless a concurrent problem involves a distal upper-extremity function or ergonomic factors in causation. A workstation ergonomic evaluation may be indicated if biomechanical stresses of work activity are factors in the causation or exacerbation of the condition.
The degree of neck pain or dysfunction can be evaluated by using standardized scales. The choice of a scale should be tailored according to the target population and the purpose of evaluation. The Neck Disability Index is useful for evaluating groups of patients, and the Patient Specific Scale is an effective tool for assessing individual patients. [81]
Medical Issues/Complications
See the list below:
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Pain complaints may escalate during the rehabilitation program.
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Pain must be treated aggressively and appropriately.
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Underlying medical conditions may need to be evaluated and treated to facilitate rehabilitation.
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The goal of therapy is functional rehabilitation and restoration with an emphasis on improving the patient's strength, endurance, and flexibility.
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When the patient reaches a plateau, as determined by using objective measurements, therapy progresses to an independent home program or a community fitness program.
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In a Toronto study, early, aggressive treatment of whiplash injury did not promote faster recovery, and a combination of chiropractic and general practitioner care was found to significantly reduce the patient recovery rate. [82]
Surgical Intervention
See the list below:
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Cervical strain without myeloradiculopathy or instability is not a condition requiring surgical intervention.
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Cervical myeloradiculopathy or instability, a possible complication of cervical strain, may require surgical intervention (eg, discectomy/fusion).
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According to Sampath and colleagues, cervical radiculopathy has a better outcome with surgical intervention than with medical treatment. However, in clinical practice, many physicians believe that most patients respond well to nonsurgical treatment. [83]
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In one study of patients with cervical spondylotic myeloradiculopathy, the short-term effects of surgery (eg, pain, weakness, sensory loss) were superior. However, at 1 year, no significant differences between surgically and nonsurgically treated groups were found. [84]
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Severe sprains of the cervical spine may result in a traumatic rupture of the intervertebral disc and ligaments, which, if not surgically treated, can lead to a significant kyphotic deformity. [11]
Consultations
A board-certified electrodiagnostic medicine specialist may be consulted for EMG and/or an NCS if radiculopathy or peripheral nerve involvement (eg, carpal tunnel syndrome) is suspected. For additional information, contact the American Association of Neuromuscular and Electrodiagnostic Medicine (formerly the American Association of Electrodiagnostic Medicine).
Surgical consultation with a neurosurgeon or orthopedic spinal surgeon may be appropriate if surgical intervention is being considered.
Psychological or psychiatric consultation may be indicated if secondary depression, anxiety, or adjustment disorder needs evaluation and treatment.
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Patients who achieve complete relief from chronic neck pain resolve all of their psychological distress. Patients with persistent neck pain also have persistent anxiety, depression, and other forms of psychological distress.
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Findings from a study of patients with whiplash-associated disorders suggested that psychosocial problems of these patients are more pronounced than their physical problems. Coping strategies seem to be a significant predictor of psychological well-being. [85]
A functional capacity evaluation (FCE) may be required if objective evaluation of the level of ability/disability needs to be documented for litigation or for determining the patient's readiness to return to work.
The degree of neck pain or dysfunction can be evaluated by using standardized scales. The choice of scale should be tailored according to the target population and the purpose of evaluation. The Neck Disability Index is useful for evaluating groups of patients, and the Patient Specific Scale is effective for assessing individual patients. [81]
Other Treatment
Upon review of several randomized, controlled trials and epidemiologic studies regarding medical and surgical interventions, published since 1993, moderate evidence exists in support of radiofrequency neurotomy. Evidence for steroid injections, botulinum treatments, and cervical discectomy is conflicting or unclear. [75, 76]
In a review of conservative treatments for whiplash, Verhagen concluded that "the current literature is of poor methodological quality and is insufficiently homogeneous to allow the pooling of results. Therefore, clearly effective treatments are not supported at this time for the treatment of acute, subacute or chronic symptoms of whiplash-associated disorders." [86] The clinician is then left with trying to do the right thing for management of whiplash injury in the face of uncertainty in the scientific community.
Injections
Injection may be indicated for patients with chronic, persistent neck pain. Injection is indicated for severe neck pain with functional impairment, particularly cervical radiculopathy. An anesthesiologist, interventional physiatrist, neuroradiologist, or other appropriately trained pain specialist may perform the injection. Types of injection include epidural, selective nerve root, or facet block injections.
Intramuscular injections of lidocaine for chronic mechanical neck disorders (MNDs) and intravenous injections of methylprednisolone for acute whiplash are effective (a single trial). Evidence of the effectiveness of epidural injections of methylprednisolone and lidocaine for chronic MND with radicular findings is limited. [87, 88]
Percutaneous radiofrequency neurotomy
Percutaneous radiofrequency neurotomy of medial branch nerve to facet joint is effective for chronic neck pain due to cervical zygapophysial joint pain.
In one study of the efficacy of radiofrequency medial branch neurotomy to treat cervical zygapophysial joint pain from whiplash injury, the potential for secondary gain did not influence the response to treatment. [89]
Using cervical zygapophysial joint pain as a model of chronic pain, investigators studied the effect of percutaneous radiofrequency neurotomy. In all patients who achieved complete pain relief, their preoperative psychological distress also resolved. [90]
Medical branch blocks of the dorsal rami of the spinal nerves supplying the facet joints are recommended by Schofferman and colleagues. If significant relief occurs on 2 occasions, radiofrequency neurotomy is recommended, providing relief for up to 8-12 months. [91]
Botulinum toxin
Whiplash-associated headache pain may be reduced with the injection of botulinum toxin A in cervical trigger points. [92] Moderate evidence has shown that intramuscular injections of BOTOX ® A for chronic MND were no better than saline injections.
Traction
Traction may be helpful. A physical therapist can provide a trial of manual and/or mechanical cervical traction within the clinic. If patients achieve positive results, the physical therapist then may offer instruction in the use of a home overhead cervical traction unit, which must be prescribed by the physician. A home cervical traction unit is most useful for patients with cervical radiculopathy.
Manipulation
Manipulation or manual therapy may offer some benefit in patients with acute or chronic neck pain. [93]
This therapy may be provided by an osteopathic physician (DO), a chiropractic physician (DC), or an allopathic physician (MD) with appropriate training. [93]
According to a study by the RAND Institute, the estimated rate of complication as a result of cervical manipulative procedures is 1 case per 1 million manipulations. [94]
Acupuncture
Acupuncture may be beneficial for pain control and should be administered by an appropriately trained and certified provider.
Bracing
Bracing with a soft cervical collar may provide symptomatic relief. The collar does not immobilize the spine; it only reminds the patient not to move his/her neck. If use of a soft cervical collar is prolonged, it may result in worsening of strength, flexibility, and function.
Moreover, using pooled analysis, a systematic review by Ricciardi et al of randomized, controlled trials indicated that nonrigid cervical collars employed for 1-2 weeks in patients with grade 1 or 2 whiplash-associated disorders offer no benefit over nonimmobilization protocols with regard to pain (as measured using the visual analogue scale score) and range of motion (ROM). The investigators reported, in fact, that nonimmobilization protocols, whether associated with physical therapy or not, appear to provide better pain relief and recovery of neck mobility. [95]
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Radiograph of the lateral cervical spine shows a normal lordotic curve.
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Radiograph of the lateral cervical spine shows straightening of the lordotic curve.
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MRI of the cervical spine shows disc protrusion.
