What is the treatment for whiplash?

Treatment for Whiplash

The first-line treatment for whiplash should include the PRICE protocol (Protection, Rest, Ice, Compression, and Elevation) combined with early mobilization and appropriate medications to reduce pain and muscle spasm. 1

Initial Management (First 24-72 hours)

• Spine Stabilization: Maintain spinal motion restriction by manually stabilizing the head to minimize motion of the head, neck, and spine 2. Avoid immobilization devices unless properly trained in their use.

• PRICE Protocol:

  • Protection: Prevent further injury to the affected area
  • Rest: Limited rest for 24-48 hours (avoid prolonged immobilization)
  • Ice: Apply for 15-20 minutes every 2-3 hours
  • Compression: Use elastic bandages to reduce swelling
  • Elevation: Keep the affected area elevated when possible 1

• Medications:

  • Topical NSAIDs: Apply 3-4 times daily directly to the affected area 1
  • Muscle relaxants: Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 3
  • Oral NSAIDs or acetaminophen: For moderate to severe pain when topical treatment is insufficient 1

Early Phase Treatment (48 hours - 2 weeks)

• Active Mobilization: Begin gentle range of motion exercises after the acute phase (48-72 hours). Active physical therapy has been shown to result in enhanced pain reduction and shortening of post-injury disability compared to passive therapy or "act as usual" approaches 4

• Avoid Prolonged Collar Use: Use of cervical collars should be kept to a minimum during the first 2-3 weeks after injury and then avoided 5

• Continue Medications: Use for short periods (up to 2-3 weeks) as muscle spasm associated with acute, painful musculoskeletal conditions is generally of short duration 3

Intermediate Phase (2 weeks - 3 months)

• Progressive Exercise: Advance from gentle range of motion to strengthening exercises as pain allows, focusing on regaining flexibility and strength 1

• Manual Therapy: Should be used as part of multimodal care, not as standalone treatment 1

• Consider Assistive Devices: Walking aids, braces, or supports when appropriate 1

• Conservative Treatment: Continue conservative treatment for at least 6 months before considering interventional approaches 6

For Persistent Symptoms (> 3 months)

• Diagnostic Evaluation: If symptoms persist beyond 3 months, consider further evaluation to identify specific pain generators:

  • The cervical facet joint is the most common source of chronic neck pain after whiplash injury, followed by disk pain 7
  • Consider medial branch blocks to determine if facet joints are the cause of pain 7

• Interventional Procedures: For persistent pain not responding to conservative measures:

  • Radiofrequency treatment of the medial branch of the dorsal ramus is recommended for chronic cases 6
  • Avoid Botulinum toxin A and intra-articular corticosteroid injections, which have negative recommendations 6

Important Considerations

• Risk Factors for Poor Recovery: Older age, presence of interscapular or upper back pain, occipital headache, multiple symptoms, reduced cervical range of motion, neurological deficits, and pre-existing degenerative changes 5

• Avoid:

  • Prolonged immobilization
  • Direct application of ice to skin (use a barrier such as a thin towel) 2
  • Routine imaging unless there are red flags suggesting serious pathology 1
  • Opioids, including tramadol 1

• Prognosis: While most patients recover within 3 months, persistent neck pain after 2 years is reported by more than 30% of patients 5

Special Situations

• Suspected Cervical Spine Injury: If any of these risk factors are present, suspect spinal injury 2:

  • Age ≥65 years
  • Motor vehicle, motorized cycle, or bicycle crash
  • Fall from greater than standing height
  • Tingling in extremities
  • Pain or tenderness in neck/back
  • Sensory deficit or muscle weakness in torso/upper extremities

• Workplace Injuries: May require workplace modifications and vocational rehabilitation 1