Pearls of Wisdom: Chronic Whiplash
Marilyn is a 48-year-old woman with a history of fibromyalgia, depression, obesity, irritable bowel syndrome, and temporomandibular joint disorder. She is a new patient who comes to your office to establish care and obtain medication refills for milnacipran (for fibromyalgia), celecoxib and butalbital/acetaminophen (for migraines), carisoprodol and cyclobenzaprine (for muscle spasms), paroxetine (for depression), and zolpidem (for sleep).
She has been wearing a soft cervical collar for the past 4 months due to cervical strain (whiplash) from a rear end collision auto accident 4 months prior. Her last physician certified her as disabled for 6 months. Cervical spine imaging shows osteoarthritic changes consistent with age, but no other pathology.
Marilyn has seen other patients at the physical therapist who are wearing rigid cervical collars and wants to know if that would be preferable in her circumstance. She has completed a 3-month course of physical therapy and doesn’t want to do any more, but finds that her neck pain and spasm continue to disable her.
How would you advise the patient?
A. Use of a cervical collar has not been shown to improve outcomes after whiplash injury.
B. Outcomes after whiplash injury are only improved during the first week after whiplash.
C. Outcomes after whiplash are worsened by the use of a cervical collar.
D. Outcomes after whiplash are generally improved over the long term, but require at least 12 hours daily use to be effective.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
Answer: Use of a cervical collar has not been shown to improve outcomes after whiplash injury.
Andrew Malleson has written a lengthy exposition1 (over 500 pages!) to help dispel myths associated with what both he and I believe to be largely a fig newton of the American imagination: chronic whiplash.
In studies from Europe, where speed and vehicle size-matched patients are followed, essentially no one reports cervical strain symptoms persisting beyond a few weeks. One of the essential messages documented throughout Malleson’s remarkable book is that when people are taught to expect to have pain, and are rewarded for it (eg, monetary reward, time off work, sympathy, etc), it is no wonder that they have it!
For persons with cervical spine injury that sustain fracture or disk rupture, it is no surprise that adverse symptoms may be protracted. However, in the absence of such readily identifiable pathology, how do we go about explaining persistent pain? And in the absence of explanation, how do we help people to get better?
Literature
In the United States, there are over 1 million auto accidents each year. A large study of cervical strain victims was unable to discern benefit from use of cervical collar.2 Indeed clinicians would be wise to avoid endorsing cervical collars in several discrete circumstances. I learned of a lawsuit filed by a patient who had received a cervical collar in the emergency department. When she wore the collar on her drive home (note: she was the driver) she claimed that inability to move her head around because of the collar—a limitation she claimed was not explained to her by attending physicians—resulted in her not seeing an oncoming vehicle with which she subsequently collided.
If simple musculoskeletal cervical strain follows in the pathophysiological footsteps of lumbosacral strain, then the sooner we get off the “protect and splint the area” bandwagon and onto the “do as much as you can comfortably accomplish,” the better off our patients will be.
What’s the “Take Home”?
There is reason to be skeptical about the veracity of protracted painful symptoms following simple musculoskeletal cervical strain (whiplash) in the absence of other demonstrated pathology, such as fracture, spinal stenosis, or herniated disk. Supporting our patients with cervical strain does not mean encouraging withdrawal from life activities. To the contrary, such patients should be encouraged to be as physically active as possible. Cervical collars can impede physical activity, and—with the possible exception of the hyperacute phase of injury immediately post-trauma—should generally be discouraged as a long-term intervention.
References:
- Malleson A. Whiplash and Other Useful Illnesses. Montreal, Canada: McGill-Queen’s University Press; 2003.
- Genesis P, Miller L, Gallagher EJ, et al. The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med. 1996;3(6):568-573.