What is the management of whiplash?

Management of Whiplash

For whiplash management, active treatments are recommended over passive approaches, with topical NSAIDs as first-line pharmacologic therapy and early mobilization to maintain usual activities rather than rest and immobilization. 1

Initial Assessment and Treatment

Pharmacologic Management

• First-line therapy: Topical NSAIDs with or without menthol gel to reduce pain and improve function 1
• Second-line options:
  • Oral NSAIDs to relieve pain or improve function 1
  • Oral acetaminophen to reduce pain 1
  • Avoid opioids including tramadol (conditional recommendation against their use) 1

Non-pharmacologic Interventions

• Early active mobilization rather than rest and immobilization with cervical collars 2, 3
• Specific acupressure to reduce pain and improve physical function 1
• Transcutaneous electrical nerve stimulation (TENS) to reduce pain 1
• Physical therapy focusing on:
  • Encouraging optimal postural alignment at rest and during functional activities
  • Even distribution of weight in sitting, transfers, standing, and walking to normalize movement patterns 1
  • Graded activity to increase normal movement patterns

Treatment Approach Based on Phase

Acute Phase (0-6 weeks)

1. Provide clear information about the condition and expected recovery 3
2. Treat pain effectively with appropriate analgesics (topical NSAIDs preferred) 1
3. Encourage maintenance of usual activities rather than rest 2, 3
4. Apply heat therapy for pain relief 1
5. Consider massage for pain management 1

Subacute Phase (6 weeks-3 months)

1. Continue active treatment approaches 4
2. Progress physical therapy with focus on return to normal activities
3. Address any psychosocial factors that may contribute to persistent symptoms
4. Continue appropriate pain management with non-opioid medications

Chronic Phase (>3 months)

• If symptoms persist despite conservative treatment for at least 6 months, interventional treatments may be considered 4
• Note: Limited evidence exists for effective treatments in chronic whiplash, as most studies focus on acute/subacute phases 2, 5

Risk Factors to Address

• High headache frequency (≥7 days/month) 1
• History of anxiety or depression 1
• Physical inactivity 1
• Prolonged sick leave 1
• Self-reported whiplash 1
• Smoking (tobacco use) 1

Common Pitfalls to Avoid

1. Prescribing cervical collars or recommending prolonged rest - these approaches may delay recovery and lead to muscle deconditioning 2, 3
2. Overreliance on passive treatments - active interventions show better long-term outcomes 6
3. Prescribing opioids - these should be avoided for whiplash management 1
4. Failing to address psychosocial factors - these can contribute significantly to persistent symptoms
5. Ordering unnecessary imaging - unless specific red flags are present, routine imaging is not recommended in the acute phase

By focusing on early active mobilization, appropriate pain management with non-opioid medications, and encouraging maintenance of usual activities, most patients with whiplash will experience improvement in symptoms and function.