What is the recommended treatment for whiplash injury?

Whiplash Injury Treatment

Early mobilization with gentle range of motion exercises is the most effective approach for reducing pain and disability in patients with whiplash-associated disorders (WAD). 1

Initial Management (First 1-2 Weeks)

Pain Management

• First-line: Non-opioid analgesics, particularly oral NSAIDs 1
  • Apply topical NSAIDs directly to the affected area 3-4 times daily for localized pain relief with fewer systemic side effects 1
  • Acetaminophen as third-line when NSAIDs are contraindicated 1
  • Avoid opioids as they are not more effective than NSAIDs and carry significant risks 1

Physical Interventions

• Implement PRICE protocol for the first 24-48 hours 1:

  • Protection: Prevent further injury
  • Rest: Limited to 24-48 hours only
  • Ice: Apply for 15-20 minutes every 2-3 hours
  • Compression: Using elastic bandages
  • Elevation: Of the injured area above heart level

• Muscle relaxants: Consider cyclobenzaprine as an adjunct to rest and physical therapy for relief of muscle spasm, but only for short periods (up to 2-3 weeks) 2

Rehabilitation Phase (2-12 Weeks)

Active Treatment Approaches

• Early mobilization: Begin gentle range of motion exercises as soon as possible 1
• Active physical therapy: Significantly reduces disability period and pain compared to passive therapy or no intervention 1
• Graded physical exercise: Gradually increase intensity and/or complexity over time (minimum once weekly for 4 weeks) 3
  • Include general physiotherapy, sensorimotor training, aerobic and anaerobic training 3

For Specific Symptoms

• For vestibular dysfunction: Consider vestibular rehabilitation including otolith manipulating procedures, habituation exercises, adaptation exercises, substitution training, and balance training (minimum once weekly for 4 weeks) 3
• For neck and spine issues: Consider manual therapy in the form of hands-on mobilization and/or manipulation of the spine 3

Duration of Treatment

• Exercise-based treatment should be at least 3 months in duration 3
• Most patients recover within 3 months, but persistent neck pain is reported by more than 30% of patients after 2 years 1

Treatment Monitoring

• Use patient-reported outcome measures (PROMs) to monitor response to treatment 3
• Measure physical impairments (range of motion, strength) and psychosocial factors 3
• Consider further evaluation if symptoms persist beyond 3 months 1

Prognosis Factors

• Poor outcome predictors include: 1
  • Older age
  • Presence of interscapular or upper back pain
  • Occipital headache
  • Multiple symptoms
  • Reduced cervical range of motion
  • Neurological deficits
  • Pre-existing degenerative changes

Imaging Considerations

• Imaging plays a limited role in diagnosis of WAD and has little usefulness in predicting prognosis 1
• When indicated, CT is preferred over radiography (sensitivity 98% vs 36%) 1
• MRI may show soft tissue injuries but tends to overestimate their severity 1

Special Populations

• Workers with occupational injuries: May require workplace modifications and vocational rehabilitation 1
• Elderly patients: May need longer recovery periods and modified exercise programs 1

Recent evidence from systematic reviews supports that active treatments show beneficial long-term effects compared to passive treatments 4, 5, reinforcing the recommendation for early mobilization and active exercise therapy in the management of whiplash injuries.