CLINICAL PRACTICE: Therapeutic review
Whiplash: still a pain in the neck
Edi Albert, MBChB, MSc, MRCGP, FRACGP, is Senior Lecturer in General Practice and
Rural Health, University of Tasmania.
Hilton Francis, MBBS, FRACP, is a rheumatologist and specialist in pain management,
Calvary Hospital, Hobart, Tasmania.
Andrew Elkerton, BMedSci, MBBS, FRACGP, is a general practitioner, Hobart,
BACKGROUND Whiplash is a common problem, particularly following motor vehicle
accidents and may have significant sequelae in terms of disability and financial
compensation. Recent research has demonstrated that a number of commonplace medical
practices as well as the compensation system may lead to unfavourable outcomes.
OBJECTIVE This article discusses recent research into whiplash and its implications
for clinical practice.
DISCUSSION A full assessment of biopsychosocial factors in the acute phase of the injury
is essential to predict those at risk of chronicity. Simple therapeutic and educational
measures should be employed and early referral to a psychologist or pain specialist
considered for those at high risk.
T he term ‘whiplash’ is commonly used may result from rear end or side impact • Are there any features I can pick up
in Australia in both professional and motor vehicle collisions, but can also early that would predict an
lay circles. It is often used in the context occur during diving or other mishaps. unfavourable outcome?
The impact may result in bony or soft
of motor vehicle accidents and carries • How should I manage a person with
tissue injuries (whiplash injury)’.2
with it the notion of chronicity and com- acute whiplash injury?
pensation. It is the most common injury In this article the term ‘whiplash’ is used • What is the likely prognosis for people
following motor vehicle accidents and is to describe such injuries in those patients with acute whiplash injury?
an important cause of chronic disability in who do not have a cervical fracture. An • What is late whiplash syndrome?
the general population. 1 A number of acute whiplash injury can often develop • What can I do for patients with late
factors have hindered the development of into a chronic disorder known as late whiplash syndrome?
a better understanding and approach to whiplash syndrome. It is the patient who
the management of whiplash. These develops chronic symptoms who becomes How do I know if it’s
include: variable definitions of the term difficult to manage.
‘whiplash’, the difficulty of extricating a As with any clinical situation a thorough
definable physical condition out of its Issues for the general history and careful examination is impor-
psychosocial and legal context, and a
practitioner tant. The following features are
history of poorly designed research that There are a number of important, practical suggestive of whiplash:3
has resulted in difficulties in establishing issues for the general practitioner and these • history of neck hyperextension/
its epidemiology and an evidence based can be framed as the following questions: flexion/rotation (may be recent or old)
approach to its management. • How do I know if it’s whiplash? • cervical fracture/subluxation excluded
In 1995 the Quebec Task Force • How do I decide whether to X-ray a (using Canadian C-spine rule Table 1)
defined whiplash as: patient with neck pain after an acci- • disabling neck pain with or without
‘an acceleration/deceleration mecha- dent that might be expected to referral to shoulder or arm
nism of energy transfer to the neck. It produce whiplash injury? • muscular spasm
2 • Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003
Whiplash: still a pain in the neck n
Table 1. The Canadian C-spine Table 2. Yellow flags: psychosocial issues to explore in the history5
Attitudes and beliefs about back pain
• Patients must undergo radiography Belief that pain is harmful
if they are judged to be at high risk Belief that all pain must be abolished before attempting to return normal activity
due to age (>65), dangerous
Passive attitude to rehabilitation
mechanism of injury or postinjury
• Patients may safely undergo Use of extended rest
assessment of active range of motion Reduced activity level with significant withdrawal from activities of daily living
if they have all five low risk Avoidance of normal activity
characteristics: absence of midline Report of extremely high intensity of pain, eg. above 10, on a 0-10 visual analogue
tenderness, normal level of alertness, scale
no evidence of intoxication or
Sleep quality reduced since onset of pain
abnormal neurological findings, and no
painful distracting injuries. Compensation issues
• Patients DO NOT require cervical spine Lack of financial incentive to return to work
radiography if they are able to actively Current compensation claim
rotate the neck 45 degrees to the left History of claim(s) and/or extended time off work due to injury or other pain problem
and right, regardless of pain. Health professional(s) sanctioning disability and/or not providing interventions that will
Experience of conflicting diagnoses or explanations for pain, resulting in confusion
Advice to withdraw from job
• point tenderness Fear of increased pain with activity or work
• decreased range of movement Depression (especially long term low mood)
• stress, anxiety and/or depression often Feeling under stress and unable to maintain sense of control
• posterior cervical sympathetic syn- Over protective partner, socially punitive partner
drome including headaches, facial Extent to which family members support any attempt to return to work
formication (sensation of ants crawl- Lack of support person to talk to about problems
ing over the face) Work
• with chronic symptoms, secondary History of manual work (including nurses)
gain may be present, eg. compensation Work history, including patterns of frequent job changes, experiencing stress at work,
for accident. job dissatisfaction, poor relationships with peers or supervisors, lack of vocational
How do I decide whether Belief that work is harmful; that it will do damage or be dangerous
to X-ray a patient with Unsupportive or unhappy current work environment
neck pain after an accident Low educational background, low socioeconomic status
that might be expected to Job involves shift work or working unsociable hours
produce whiplash injury?
The Canadian C-spine rule4 is a simple
evidence based guide that identifies those
trauma patients who require cervical Are there any features whiplash [but that] it is becoming obvious
spine radiography based on three simple I can pick up early that that the insurance and compensation
clinical points. It is shown in Table 1. CT would predict an systems have a large impact upon recov-
scanning of the cervical spine is not unfavourable outcome? ery from acute whiplash injuries’. They
helpful, unless specifically investigating A recent systematic review of the progno- also concluded that older age, female
the possibility of fractures in the acute sis associated with acute whiplash injury gender, baseline neck pain, baseline
phase. MRI scans are generally unhelpful, has provided inconclusive results.6 The headache intensity, and baseline radicular
even with patients with chronic pain, authors concluded that: ‘...there is little symptoms are predictors of delayed
unless they have specific localising neuro- consistency in the literature about the recovery. A more recent prospective
logical signs. prognostic factors for the recovery of study suggests that cervical range of
Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003 • 3
n Whiplash: still a pain in the neck
Time of injury ASSESS History If yellow flags Intensive counselling/
– pain clinic
No Yes referral – may require surgery
– analgesia education process
– ensure sleep Encourage range of
– (NOT collar!) movement
Distress If yellow flags Intensive counselling/
– pain clinic
3–10 days REASSESS Analgesia – psychologist
– GP talk to therapist to ensure
common message given to patient
– set time limit (ie. not longer than
Patient should have ~ 50% If pain perceived to be – counselling
reduction in symptoms getting worse – early referral to pain
Patient should continue to
display gradual improvement
If after 3 months patient
still has significant pain Specialist referral
Figure 1. Flowchart outlining the treatment of whiplash injury
4 • Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003
Whiplash: still a pain in the neck n
motion is a useful estimator of future term care and to reduce the likelihood of whiplash syndrome. 13 In other words,
handicap.7 chronic pain. 12 Paracetamol should be although patients may have continuing
considered as a first line drug. Ibuprofen pain, parasthaesiae and other symptoms,
Yellow flags can be used as an alternative. Stronger recognisable pathology is usually not
The concept of ‘yellow flags’ was devel- analgesia is acceptable on a short term identified in the neck.
oped for low back pain (Table 2).5 Yellow basis. A heat pack can also be used to In many western societies confound-
flags are psychosocial factors that relieve pain and assist with mobilisation. ing factors have made it difficult to define
increase the risk of developing, or perpet- Diazepam is commonly used for and therefore understand the natural
uating long term disability and work loss muscle spasm although there is no evi- history of acute whiplash injury. Studies
associated with pain. There has been dence to support its use. Poor quality of in Canada have shown rates of chronic
insufficient research to validate the sleep is suspected to be a factor in devel- symptoms approaching 50% at one year
yellow flag concept in neck pain. In prac- oping chronic symptoms. Simple postcollision. At the other extreme,
tice however, it is reasonable to adopt the measures to promote sleep would seem recent studies in Lithuania, Germany and
yellow flag approach for whiplash. At the reasonable. Anecdotally, firm supportive Greece have shown that resolution of
first and subsequent consultations a full pillows may be supportive and short term symptoms occur in over 90% of patients
psychosocial history should be taken to benzodiazepine use may be justified in by four weeks postcollision, with the
identify factors that may suggest the acute some cases. The potential benefits of ben- remainder having improved by three
injury could progress to become a chronic zodiazepine use must be weighed against months. These studies also showed the
problem. These factors can be thought of its side effects: drowsiness may prevent prevalence of chronic neck pain was the
in terms of: attitudes, beliefs, behaviours, patients from mobilising early, and same in the general population as it was
compensation issues, emotions, family dependence is always a possibility. in those who had been involved in a
and work situation. One role of the GP is to identify motor vehicle accident.13
‘yellow flags’ at the first opportunity and, Why is there so much variation and
How should I manage where possible, intervene in the process. how do you explain persisting symptoms
a person with acute This may take the form of a: in the absence of pathology? The biggest
• simple educational process to correct influences that over-arch all the yellow
Clearly, treatment will vary depending erroneous beliefs flags relate to fiscal compensation for
upon what is found from the history and • short course of cognitive behavioural injury and a national culture or percep-
examination, and how long it is since the therapy, or tion of the likelihood of chronic problems
whiplash injury occurred. Figure 1 sum- • early referral to a psychologist or pain in both the lay population and health pro-
marises the recommended treatment and clinic if indicated. fessionals.
referral pathways. Once two or more health professionals Elimination of compensation for
Four recent reviews of the literature become involved in the management of a whiplash injury in Canada has shown a
provide a basis for treating acute patient it is important for effective com- decreased incidence and improved prog-
whiplash injury.8–11It is important to note munication to take place so as to ensure nosis of acute whiplash injury.1 Indeed, in
that there are relatively few high quality the patient receives a consistent message. countries such as Lithuania, Greece and
studies to provide good evidence for It is vitally important that health profes- Germany there never has been monetary
treatment. It is clear however, that immo- sionals do not sanction or collude with compensation available for acute
bilisation, rest and soft collars are behaviour or beliefs that are likely to whiplash injury. This has influenced
detrimental. Manual therapies, such as adversely affect outcomes. peoples’ expectations. It is said of the
physiotherapy are commonly employed, Greeks that:
but currently there is no good evidence to What is the likely
‘perhaps by not receiving (and then
support their use. Patients should be
prognosis for people with
failing to respond to) multiple thera-
acute whiplash injury?
advised to mobilise early and maintain pies, no anxiety is created. Patients do
usual activities as much as possible. Neck Acute whiplash injury has been described not change their activities to any extent,
exercises to encourage range of motion above as an acute soft tissue injury. It is or stop work, and will not develop poor
are commonly employed, but have been recognised that certain factors predispose posture or poor physical fitness.
shown not to be more effective than non- to continuing problems, commonly Whiplash victims in Greece do not hear
frightful diagnoses that mean to them
specific mobilisation. referred to as late whiplash syndrome.
chronic disability. In other countries,
Patients should be given adequate Research has also shown that there is no
however, the media and medical com-
analgesia. This is important for both short ‘chronic injury’ component of late
Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003 • 5
n Whiplash: still a pain in the neck
munity attention to whiplash enforces injury’. Side effects from medications • diagnose and treat depression and
the notion that it causes chronic pain’.14 (particularly benzodiazepines and nar- anxiety where these coexist
cotic analgesics) may be attributed to the • involve a multidisciplinary pain clinic
What is late whiplash chronic injury. Even new, unrelated at an early stage where there is a like-
benign symptoms may be wrongly attrib- lihood of the patient developing
Given the combination of lack of physical uted to the chronic injury. These new chronic symptoms
pathology, and the association with mon- symptoms are themselves substrate for • ensure effective communication
etary compensation there has been a yet more symptom amplification. between health professionals so that
tendency to label patients with either a Therefore, the biopsychosocial model the patient receives a consistent posi-
‘psychiatric problem’ or as a ‘malingerer’. is not a ‘psychogenic’ one that assumes tive message.
This has been unhelpful. Patients can end the physical symptoms are merely the
up on the merry-go-round of specialist expression of psychological disorder, but SUMMARY OF
referrals and normal investigations - rather suggests that what the patient IMPORTANT POINTS
which only serves to increase their symp- expects, how they perceive symptoms,
toms, stimulate depression and anxiety, and how they focus and attribute symp-
• Whiplash is the commonest injury
and prolong their disability. Therefore, toms will in turn alter the character of following a motor vehicle accident
they may become dependent upon nar- those symptoms and the patient’s behav- and is a common cause of disability.
cotic analgesics. iour, and that the symptoms have various • Acute whiplash injury should be
The biopsychosocial model 13 of physical sources in some cases. If you add managed by simple analgesia, early
whiplash injury considers there to be a to this a contribution from anxiety, mobilisation, maintaining normal
triad of influences that lead to chronic depression and compensation systems, activities, and promoting the fact
that the underlying damage is not
problems: then late whiplash syndrome is born. serious, and should resolve quickly -
• symptom expectation most people will have resolution of
• symptom amplification, and What can I do for patients symptoms in 2-3 weeks.
• symptom attribution.
with late whiplash
• X-rays should only be performed
syndrome? when indicated by the Canadian C-
Expectation Clearly, the first answer to this question spine rule.
The combination of cultural factors, is: ‘do your best to prevent it’! However, • There are number of factors that
may be obtained from history and
added to the fact that motor vehicle acci- there is no good evidence from the litera-
examination that predict a poor
dents often do produce serious injury lead ture about which interventions are most outcome (‘yellow flags’).
patients to expect their injury to be trou- effective. From a GP’s perspective it is • Active interventions need to be put in
blesome. The fact that acute pain can important to: place to address these psychosocial
indeed be very unpleasant serves to com- • throw away the soft collar! ‘yellow flags’.
pound this. • resist the urge to over treat and over • Compensation systems and lay and
investigate patients. In particular use medical cultures have a marked
Amplification the lowest doses of the simplest med- effect on recovery from the acute
Symptoms may be amplified by unhelpful ications possible
• Chronic problems (late whiplash
behaviours that result from patients’ • reward patients for ‘becoming well’
syndrome) are best understood and
expectations. Patients may withdraw, rather than for remaining ill. Assist managed using the biopsychosocial
change their posture or have their symp- and encourage a return to normal model.
toms amplified by lack of sleep or anxiety. activities
Patients who are asked to keep pain • do not sanction behaviours that
diaries will focus on their symptoms and promote disability
therefore prolong them. Poor posture will • do not enhance the patient’s own Acknowledgments
generate pain in healthy subjects and most expectations of a poor outcome and
certainly amplify it in those with whiplash. chronic disability The authors wish to acknowledge the
• reduce, where possible, the influence support of Dr Geoff Chapman and Ms
Attribution of lawyers, and especially discourage Carolyn Field from the Southern
Symptom attribution occurs when, for the use of symptom diaries Tasmanian Division of General Practice.
example, poor posture creates new pain • continue the education process
that the patient believes to be ‘chronic regarding behaviours and beliefs Conflict of interest: none declared.
6 • Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003
Whiplash: still a pain in the neck n
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al. The Canadian C-spine Rule for radiog-
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JAMA 2001; 286(15):1841.
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assessing psychosocial yellow flags in
acute low back pain: Risk factors for long
term disability and work loss.
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Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003 • 7