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After the crash: Treating whiplash


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Originally posted September 2005

By James F. Veronesi, RN, MSN

James Veronesi is the director of nursing systems and resources at Penn State Milton S. Hershey Medical Center in Hershey, PA, and a member of the RN editorial board. The author has no financial relationships to disclose.

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 belt.

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 contro versy 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 counterparts.7

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 relief.8

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 recovery period.

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 and disability.

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.


REFERENCES

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 2005).

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), 106.

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 accidents." www.whiplash101.com/lowspeed.htm (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 2005).

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 controversy.

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.


Classifying whiplash-associated disorders

The following classification system, developed by the Quebec Task Force on Whiplash-Associated Disorders, is a widely used method of assessing injuries and neuromuscular deficits:


Classifying whiplash-associated disorders

Sources: 1. Silber, J. S., Hayes, V. M., et al. (2005). Whiplash: Fact or fiction? Am J Orthop, 34(1), 23. 2. Jaye, C. (2004). Managing whiplash injury. Emergency Nurse, 12(7), 28.

 


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