After the crash: Treating whiplash
By James F. Veronesi, RN, MSN
A rear-end collision typically results in whiplash injury—and, often, a trip
to the ED. Are you up to speed on its treatment?
“They’re gonna hit!” screams a pedestrian. Tires screech, and a split
second later there’s a loud crash. Forty-six-year-old Elaine Sands (not her
real name), who was stopped at a red light, has been hit from behind by a
driver whose last-minute stomp on the brakes failed to prevent a rear-end
collision. Witnesses see her stumble out of her car, rubbing her neck. Asked if
she’s OK, Mrs. Sands says, “My neck hurts.” She was not wearing a safety
When the ambulance arrives, the EMTs apply a Philadelphia cervical collar and
immobilize Mrs. Sands to a spine board. Her vital signs are stable. Her
assessment is essentially negative, except for the neck pain and a slight
numbness and tingling down her right arm. Mrs. Sands is transported to the
nearest trauma center for further evaluation.
In the ED, the attending physician detects point tenderness along her
posterior neck just to the right of midline. Spinal X-rays rule out a fracture
as the source of her symptoms, strongly suggesting that Mrs. Sands is suffering
from a whiplash injury to the soft tissues of her neck. If you were her nurse,
would you know what to look for and what kind of treatment to provide?
What is whiplash, anyway?
Whiplash involves a sudden movement of the head that can lead to the tearing
of muscles, ligaments, and other soft tissues. It is a common result of a
rear-end automobile collision, and can happen at low as well as high speeds.
As many as 3 million whiplash injuries occur every year in the United
States.1 The cost includes not only the $29
billion spent every year on direct medical expenses and litigation, but
decreased productivity, missed work, emotional distress, and long-term
disability, as well.2 According to the American
Academy of Orthopedic Surgeons, approximately 20% of those involved in rear-end
motor vehicle accidents develop some symptoms in the neck region, usually
within the first two days.3
Like Mrs. Sands, many whiplash victims are stopped at a traffic light when a
vehicle hits their rear bumper, pushing their car forward. The usual response
is to slam on the brakes, bringing the car to a sudden stop and causing the
driver's neck to be jerked back and forth beyond its normal limits. Supporting
tissues are stretched and may tear and bleed; the cervical spine flexes and
then extends.2,4,6 This causes a soft-tissue
injury sometimes described as neck sprain, but is more often called whiplash,
or whiplash-associated disorder (WAD).
Patients with WAD may or may not respond to conventional, noninvasive
therapies and analgesics. Symptoms often recede in the weeks following the
accident, and before long most people experience a complete recovery. But for
somewhere between 10% – 40% of patients,2
symptoms persist for months or years, prompting a great deal of debate among
healthcare professionals as to the reason. (See the box)
After a crash: The initial assessment
No definitive test for whiplash exists, which goes a long way toward
explaining the controversy surrounding its diagnosis. X-rays, of course, won't
reveal soft tissue or nerve injury, although CT scans or MRI sometimes helps.
Diagnosis is made by excluding other potential injuries, which makes your
assessment and patient history particularly important.
In addition to a direct rear-end collision, there are a number of related
factors that should raise your index of suspicion for whiplash.5-7
These include such things as the type of seat in the car and the position of the
head and body at the time of impact.2,7
Bench seats are more often linked to whiplash than bucket seats.8 Also, the further away the head is from the headrest at
the time of impact, the greater the risk of injury.2,7
In addition, the length of the patient's neck is relevant. People who have
long, swanlike necks are more at risk for whiplash than those with short necks,
and those with lower body mass are at higher risk than their heavier
When the victim arrives at the ED, start with a head-to-toe as sess ment to
rule out actual or potential life-threatening injuries, including spinal cord
injury, and any condition that requires immediate treatment. Then evaluate
signs and symptoms, based on your observation and what you have learned from
the EMS team and the patient.
In addition to neck pain or stiffness, symptoms associated with whiplash may
include headache, dizziness, paresthesias in the arm or hand, lower back pain,
temporomandibular joint (TMJ) pain, decreased range of motion, irritability,
fatigue, and sleep disturbances. While the pain or stiffness generally develops
immediately, it may be several days before other problems develop.2
It's necessary, too, to look specifically for neuromuscular deficits. The
widely accepted Quebec Classification system, summarized in the box on page 44,
is an excellent assessment tool. If the patient has pain or tenderness anywhere
along the spine, the attending physician is likely to order an entire cervical
spine series and maintain the patient on spine precautions.
Take a closer look at the cause of symptoms
Neck stiffness can be an indication of an irritated or injured facet
joint.8,9 To test for this possibility once
spinal cord injury is ruled out, place the patient in a seated position and ask
her to extend her neck and turn it to the right. If attempting to turn elicits
pain in the right side of the neck, a facet joint injury is possible; if it
causes pain on the left side or the front of the neck, this joint is probably
not involved. Repeat the process on the left side.10
Cervicogenic headaches, as those associated with neck injury are known, are
common in whiplash patients. Often the headache is the result of referred pain
from nerves irritated by the rapid extension and flexion of the neck at the
time of the collision. The greater and lesser occipital nerves, as well as
nerves in the cervical spine and jaw, may be involved. Trigger points in other
muscles can also be a source of headache.9
Dizziness following whiplash injury stems from a number of
sources.11 A stiff neck, most likely from
irritation at the level of C1 – C3, interferes with the patient's desired eye
movements. Body position data coming into the brain from the neck and eyes may
contradict information coming from the inner ear, leading to a sensation of
dizziness. Other possible causes of dizziness are spasms in the front neck
muscles pressing on trigger points and irritation of the rectus capitus
posterior minor, the muscle that connects the C1 to the dura mater. And
sometimes-though it is rare-dizziness may be the result of kinking of the
vertebral artery, which can lead to stroke.3,11
Numbness and tingling in the fingers or arm are common after an automobile
accident. So ask the patient exactly which fingers are numb to pinpoint the
level of cervical spine injury. Once neurological deficits have been ruled out,
you can reassure your patient that paresthesias typically resolve within two
months. Advise her to seek further evaluation from an orthopedist or
neurologist if the symptoms persist beyond that point. Older patients with
arthritic changes are likely to have symptoms that persist.
Back pain is typical, as well. The most likely source is the thoracic spine,
which causes pain when extension or side-bending movements bring spine facets
into contact with each other. But injury to the rib ligaments can also cause
referred back pain.9,12
The temporomandibular joint may also be affected, with pain occurring as a
result of a ligament sprain within the joint. Symptoms of TMJ include popping
or cracking in the joint, pain with chewing, and headache.8,12
While irritability, fatigue, and difficulty sleeping are frequently
associated with trauma, they're not likely to be evident immediately. Patients
who develop such lingering difficulties need understanding and emotional
support. And all patients with WAD need supportive therapy.
Getting moving helps patients heal
Ice can be applied to tender areas for the first 24 hours post-injury,
followed by gentle massage and aerobic activity such as walking. After that,
heat application may help relax tense muscles. Intermittent use of a soft
cervical collar, or even a rolled up towel, during the first three weeks
post-injury will help support the injured muscles.8
Instruct patients on the principles of good body mechanics, such as bending
at the knees to pick up the groceries or when doing any lifting. You should
explain that this reduces stress on soft tissues and helps promote
healing.9 Strength training, range-of-motion
exercises, physical therapy, and cervical traction help muscles regain their
ability to adequately support the head and neck. In some cases, strength
training in conjunction with spinal manipulation provided by a chiropractor may
also be needed.
Be sure to tell patients that over-the-counter and prescription medication
may be helpful for symptom control. There is no one "best" drug for whiplash
symptoms. Rather, the choice of medication depends upon the type, severity, and
duration of pain as well as the patient's overall health. NSAIDs such as
aspirin, ibuprofen, and naproxen (Naprosyn) may be appropriate for most
patients. But those who have severe pain may require opioid analgesics such as
codeine, hydrocodone (Vicodin), or oxycodone (OxyContin). If muscle spasm is
contributing to pain, muscle relaxants such as carisoprodol (Soma),
cyclobenzaprine (Flexeril), and methocarbamol (Robaxin) may be
helpful.2,6,8 For chronic and severe neck
pain, opioid analgesics and tricyclic antidepressants may provide optimal
If a patient has significant paresthesias of the arms, spinal injections may
offer some relief. Injections into the facet joint or the epidural space can
block transmission of pain impulses. In severe cases, and when injections do
not relieve facet joint pain, radiofrequency neurotomy may be performed. In
this procedure-which is typically effective for about nine to 18 months and can
be repeated, as needed-the nerves are heated to stop them from conducting pain
signals.9 Surgery for chronic neck pain
associated with whiplash is hardly ever necessary, and is typically reserved
for those with pressure on a nerve or the spinal cord.9
Some patients with WAD may have a long road ahead of them. To help them on
that journey, you'll need to teach them self-care. Underscore the need to
reduce stress and get adequate sleep. You should emphasize the importance of
eating a balanced diet and continuing physical therapy, if ordered, during the
It's equally important that your nursing care include ample doses of
emotional support. Make it clear that most WAD patients-even those who need
surgery-are eventually able to resume their former lifestyle. At the same time,
help them cope with the stress of what may be a prolonged period of discomfort
With nursing care, discharge instructions to take ibuprofen as needed, a
prescription for cyclo benzaprine, and a follow-up ap pointment with her
primary care provider, Elaine Sands came through with flying colors. Being up
to speed on the care patients with whiplash injury need will help ensure that
those you care for will, too.
1. Spine Research Institute of San Diego.
2005. "Epidemiology of whiplash: Incidence, risk, and prevalence of whiplash."
www.srisd.com/consumer_site (29 July 2005).
2. Silber, J. S., Hayes, V. M., et al.
(2005). Whiplash: Fact or fiction. Am J Orthop, 34(1), 23.
3. American Academy of Orthopedic Surgeons
2000. "Whiplash." http://orthoinfo.aaos.org/ (30 May
4. Grauer, J. N., Panjabi, M. M., et al.
(1997) Whiplash produces an S-shaped curvature of the neck with hyperextension
at lower levels. Spine, 22(21), 2489.
5. Childs, S. G. (2004). Cervical whiplash
syndrome: Hyperextension-hyperflexion injury. Orthop Nursing, 23(2),
6. Albert, T. "Whiplash: Neck trauma and
treatment." 2004. www.spineuniverse.com/displayarticle.php/article107.html
(10 June 2005).
7. Spinal Injury Foundation. "Low speed
(7 June 2005).
8. Jaye, C. (2004). Managing whiplash
injury. Emergency Nurse, 12(7), 28.
9. North American Spine Society. "Whiplash
and whiplash associated disorders." 2002. www.spine.org/articles/whiplash.cfm (30 May
10. Spinal Injury Foundation. Patient
resources. "Facet pain test." www.spinalinjuryfoundation.org/101_new/facet6.htm
(10 June 2005).
11. Spinal Injury Foundation. Patient
Resources. "Dizziness and whiplash." www.spinalinjuryfoundation.org/101_new/dizzines1.htm
(10 June 2005).
12. Evans, R. W. (2004). The postconcussion
syndrome and whiplash injuries: A question-and-answer review for primary care
physicians. Prim Care, 31(1), 1.
Chronic whiplash disorder: THE CONTROVERSY
The tricky thing about whiplash-associated disorder (WAD) is that it's
subjective: The patient says her neck hurts and her fingers are numb and
tingly. But nothing shows on an X-ray, and she has no neurological deficit.
She's treated for a presumed soft-tissue injury, symptoms gradually recede, and
she goes back to her usual activities. No problem.
But what about the 10% – 40% of patients who continue to suffer from pain and
disability for many months or even years? The ones who bring lawsuits seeking
big money for pain and suffering or apply for long-term disability payments?
Are they really disabled and suffering or simply looking for attention, money,
or access to painkillers? These are the patients at the heart of a
On one side are researchers who don't believe chronic WAD exists. They point
out that claims for whiplash injury account for the majority of insurance
settlements in the United States and cite studies showing that in countries
where most drivers aren't insured, whiplash injuries are virtually
non-existent. Their conclusion? WAD is all in the mind, a psychosomatic
complaint, or a ploy to reap secondary gain.
On the other side are clinicians who suggest that chronic WAD patients suffer
from post-traumatic stress disorder or spinal injuries not properly diagnosed
or treated. They point to Australian research that traces some chronic whiplash
pain to specific nerves in the neck; relief was achieved by deadening those
nerves. They also cite a Dutch program that gets chronic WAD patients back to
work with a combination of physical therapy, exercise training, occupational
therapy, counseling, and sports participation. Their stance, summed up by
neurologist Randolph Evans, an expert on whiplash: While non-organic
explanations are reasonable in some cases, most of those with chronic WAD
incurred an actual injury and are truly experiencing chronic pain.
Sources: 1. Silber, J. S., Hayes, V. M., et al. (2005) Whiplash: Fact
or fiction? Am J Orthop, 34(1). 23. 2. Weintraub, M. I. (2002).
Handicap after acute whiplash injury. Neurology, 58(1), 157. 3.
DeNoon, D. "A pain in the neck—or just a pain?" 2000. Web MD Medical News. http://my.webmd.com/content/Article/36/1728_566555.htm
(29 July 2005). 4. Kelly, J. "Comprehensive program can overcome chronic
whiplash." 2000. Web MD Medical News. http://my.webmd.com/content/Article/22/1728_55310.htm
(29 July 2005). 5. Evans, R. W. (2004). The postconcussion syndrome and
whiplash injuries: A question-and-answer review for primary care physicians.
Prim Care, 31(1), 1.
Article taken from: http://www.modernmedicine.com/modern-medicine/news/after-crash-treating-whiplash
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