Treatment Options for Whiplash
The treatment of whiplash should follow a multimodal approach with early mobilization and non-opioid analgesics as first-line interventions, avoiding immobilization devices and opioids whenever possible. 1
Initial Management (First 48-72 hours)
Non-pharmacological Interventions
PRICE protocol 1:
- Protection: Prevent further injury by avoiding aggravating movements
- Rest: Limited to 24-48 hours only
- Ice: Apply for 15-20 minutes every 2-3 hours with a barrier (thin towel) between ice and skin
- Compression: Use elastic bandages if appropriate
- Elevation: When possible, elevate the affected area
Avoid immobilization devices such as cervical collars unless specifically trained in their use 1
Manual stabilization of the head may be used to minimize motion when necessary 1
Pharmacological Management
- First-line: Topical NSAIDs applied 3-4 times daily directly to the affected area 1
- Can be combined with menthol gel for enhanced effect
- Second-line: Oral NSAIDs for moderate to severe pain 2
- Third-line: Acetaminophen when NSAIDs are contraindicated 1
- Avoid opioids including tramadol for whiplash, as they are not more effective than NSAIDs for musculoskeletal injuries and carry significant risks 2
Subacute Phase (After 48-72 hours)
Active Rehabilitation
- Begin early mobilization with gentle range of motion exercises 1, 3
- Early active intervention significantly reduces pain intensity and sick leave compared to standard intervention with rest and collar use 3
- Progress to strengthening exercises as pain allows 1
- Massage therapy shows moderate evidence for pain reduction 1
Pharmacological Options
- Muscle relaxants: Cyclobenzaprine can be used as an adjunct to physical therapy for up to 2-3 weeks for muscle spasm 4
- Topical analgesics:
- Avoid benzodiazepines: Diazepam shows no substantial advantage in the treatment of whiplash 7
Chronic Phase (Beyond 3 months)
For Persistent Symptoms
- Individualized daily exercise regimens focusing on regaining flexibility and strength 1
- Manual therapy as part of a comprehensive care plan, not as standalone treatment 1
- Consider pain generators: If symptoms persist beyond 3 months, evaluate for specific pain generators, with cervical facet joints being the most common source of chronic neck pain after whiplash 1
- Radiofrequency treatment of the medial branch may be considered for persistent facet-mediated pain (2 B+ evidence) 8
Interventions to Avoid
- Botulinum toxin A injections are not recommended (2 B- evidence) 8
- Intra-articular corticosteroid injections are not recommended (2 C- evidence) 8
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
- Pre-existing degenerative changes 1
Important Considerations
- Routine imaging is not recommended unless there are red flags suggesting serious pathology 1
- Address psychosocial factors that may contribute to pain persistence 1
- Consider workplace modifications for ergonomic support in occupational injuries 1
- Most patients recover within 3 months, though more than 30% report persistent neck pain after 2 years 1
Treatment Pitfalls to Avoid
- Prolonged immobilization: Can lead to muscle deconditioning and delayed recovery
- Overreliance on passive treatments: Active interventions show better outcomes
- Delayed mobilization: Early active intervention is more effective than delayed intervention 3
- Opioid prescribing: Opioids are not more effective than NSAIDs for musculoskeletal injuries and carry significant risks of dependence 2
- Ignoring psychosocial factors: These can contribute significantly to chronicity
The evidence strongly supports active intervention approaches over passive treatments for whiplash, with early mobilization showing better long-term outcomes for pain reduction and return to function 3.