Neck Whiplash

Written by Tele Demetrious, Physiotherapist, BPhysio(Hons)
Reviewed by Brett Harrop, APA Sports Physiotherapist, BPhysio(Hons), MPhysio(Sports Physio)
Updated:

Injuries > Neck & Head > Neck Whiplash

(Also known as Whiplash, Whiplash Syndrome, Acceleration / Deceleration Injury, Neck Sprain)

What is neck whiplash?

Neck whiplash is the term given to an acceleration / deceleration injury of the neck that typically occurs during motor vehicle accidents or contact sports. This may cause damage to numerous structures within the neck resulting in a variety of symptoms such as pain and stiffness in the neck.

The spine (neck) comprises of many bones known as vertebrae. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally (figure 1). In addition, the spine has muscles situated at the front, back and sides of the neck supporting these joints. During a typical acceleration / deceleration injury of the neck involving a forward / backward movement, stretching and compressive forces are placed on the joints, muscles, ligaments and nerves primarily at the front and back of the neck. This may cause widespread damage to these structures if the forces are beyond what the tissues can withstand. When this occurs the condition is known as neck whiplash.

Anatomy of neck whiplash

Figure 1 – Anatomy of Neck Whiplash


Causes of neck whiplash

Whiplash injuries most commonly occur in motor vehicle accidents whereby the neck is thrown forcefully forwards and then backwards. This condition is also frequently seen in contact sports, whereby the usual mechanism of injury is a forceful collision with another player resulting in a jolting force to the head and neck.

Whilst a forward, backward movement of the neck is the typical mechanism of injury in patients with this condition, it is also common for whiplash injuries to involve a sideways or rotation force either in isolation or in addition to the typical forward / backward movement of the head and neck. When this occurs, tissue damage and symptoms are typically distributed more unevenly across the neck, with symptoms usually being worse on one side of the body.


Signs and symptoms of neck whiplash

Patients with this condition usually experience a sudden onset of neck pain during the causative activity. However, occasionally, in less severe cases, patients may experience little or no pain at the time of injury. In these instances, symptoms typically increase over the following 2 to 3 days and may be most prominent at night or first thing in the morning.

Patients with neck whiplash usually experience pain in the front, back or sides of the neck that sometimes may be accompanied by pain radiating down one or both arms (sometimes as far as the hand and fingers) or into the shoulder blade region, or in some cases, headaches.

Pain may be sharp or dull, with symptom intensity varying between mild and severe usually based on the forces involved at the time of injury. Patients with this condition also commonly experience stiffness or restricted movement in their neck which can range from mild to severe. Muscle spasm, pins and needles, numbness, a burning sensation or weakness may also be present. Occasionally the neck may be noticeably out of alignment, with pain preventing the patient from straightening the neck. Some patients may also feel that their head is too heavy and can experience difficulty lifting their head off a pillow.

Symptoms associated with whiplash are often exacerbated by sustained postures such as reading, driving, sitting at a computer, using a mobile phone or watching television. Symptoms may also increase during activities using the arms in front of the body (such as cooking, ironing, vacuuming etc.), prolonged sitting (especially if slouched), lifting and with certain neck movements involving rotation, side bending, bending forwards or backwards. Sneezing may also aggravate symptoms. Patients with neck whiplash often experience pain and stiffness that is worse first thing in the morning.


Diagnosis of neck whiplash

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose neck whiplash. Investigations such as an X-ray, MRI or CT scan are usually required to rule out serious injury.


Prognosis for neck whiplash

Most patients with mild to moderate cases of neck whiplash heal quickly and have a full recovery with appropriate physiotherapy treatment. In these instances, recovery may take weeks to months. In severe cases, recovery may be significantly longer. Patients with severe neck whiplash may also have an increased likelihood of developing degenerative changes to their joints (neck arthritis) resulting in potential long term problems with restricted movement and pain.


Treatment for neck whiplash

Prior to commencing treatment, all patients with neck whiplash should undergo assessment from a medical professional to rule out serious injury (such as spinal fracture).

The success rate of treatment in patients with this condition is largely dictated by injury severity and patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free. Activities which place large amounts of stress through the neck should also be minimized, including: prolonged sitting, lying or standing in poor posture (figure 2,3), head looking down activities, shoulders forward activities, excessive twisting of the neck and lifting. Recovery periods in positions of minimal stress for the neck (such as lying, walking or standing in optimal posture) are generally recommended as a break from repetitive or prolonged activity to prevent symptom exacerbation. Rest from aggravating activities allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities and a reduction in recovery periods is indicated provided there is no increase in symptoms.

Poor Sidelying Posture

Figure 2 – Poor Sidelying Posture

Poor posture

Figure 3 – Poor Posture

Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to lead to the condition becoming chronic. Immediate treatment for patients with neck whiplash is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times.

Patients with whiplash should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain, night pain or pain with rest). For patients with this condition, the R.I.C.E. regime should primarily comprise of rest from aggravating activities (this may include the use of a Soft Cervical Collar, Postural Support, Postural Taping or Contoured Pillow) and regular icing (i.e. 20 minutes every 2 hours) using an ice pack wrapped in a damp tea towel. Anti-inflammatory and pain relieving medication may also be indicated to reduce symptoms and hasten the healing process by reducing the pain and swelling associated with the condition. This should be discussed with the patient’s treating doctor or pharmacist prior to commencement. Once inflammation has settled, heat treatment may be beneficial to reduce muscle spasm and pain associated with this condition.

Manual “hands-on” therapy from the physiotherapist such as massage, trigger point releases, joint mobilisation, dry needling, traction and electrotherapy can hasten healing and speed recovery in patients with this condition. This can generally commence once the physiotherapist has indicated it is safe to do so.

Patients with this condition should perform early movement and postural exercises to prevent stiffness from developing and to ensure the neck is functioning correctly. Cardiovascular and functional strengthening exercises placing minimal force through the neck should also be performed to maintain fitness, strengthand mobility provided they do not increase symptoms. This may include regular walking, use of a stationary exercise bike (in good posture), hydrotherapy exercises (designed by a physiotherapist) or resistance exercises (such as the use of resistance bands or weights). Clinical Pilates exercises are also often recommended. Generally patients should begin with a small duration of low intensity exercise and gradually build up the frequency, duration and intensity of training provided there is no increase in symptoms. The treating physiotherapist can advise which exercises are most appropriate and when they should be commenced.

Patients should also pay particular attention to maintaining good posture as much as possible to minimize stress on the neck (a Postural Support, Postural Taping or Contoured Pillow may be required). This is particularly important when sitting, driving and lying (particularly at night). Optimal sitting posture can be obtained by sitting tall on an appropriate chair, with your bottom in the back of the chair and a lumbar support (or a pillow or rolled up towel) in the small of your back. Your shoulders should be back and your chin should be tucked in slightly (figure 4). Regular breaks from sitting (ideally with lying, walking or standing in optimal posture) are generally recommended as required (for example every 20 – 30 minutes) to prevent symptom exacerbation.

Optimal Sitting Posture

Figure 4 – Optimal Sitting Posture

In lying, optimal posture can be achieved by lying on your back with an appropriate size Contoured Pillow supporting your neck (thinner pillows are generally better provided they are comfortable and do not cause an increase in symptoms). If lying on your side, it is important to lie as straight as possible (figure 5) and to avoid curling up into the fetal position (figure 2). A contoured pillow should be used that is an appropriate size to bridge the gap between your bed and neck and prevent your neck from tilting down to the bed (if the pillow is too thin) or away from the bed (if the pillow is too thick). If one side of your neck is sorer than the other, it is generally better to lie with the sorer side up provided this is comfortable and does not increase symptoms. A pillow may also be placed between your knees for comfort. Lying on your stomach is generally not recommended since it places considerable stress on your neck. This occurs since you have to turn your head almost 90 degrees to breath. If you have to sleep on your stomach, your posture can be improved by placing your head on the edge of the pillow, and only turning your head slightly to the side. This allows you to breathe whilst minimizing stress and rotation of the neck.

Optimal Sidelying Posture

Figure 5 – Optimal Sidelying Posture

In the final stages of rehabilitation, a graduated return to sport or activity can occur as guided by the treating physiotherapist provided symptoms do not increase.


Physiotherapy for neck whiplash

Physiotherapy treatment for patients with this condition is vital to hasten the healing process and ensure an optimal outcome. Treatment may comprise:

  • joint mobilization
  • soft tissue massage
  • dry needling
  • electrotherapy (e.g. ultrasound)
  • traction
  • the use of a soft cervical collar
  • postural taping
  • postural bracing
  • the use of a lumbar roll for sitting
  • ice or heat treatment
  • education
  • anti-inflammatory advice
  • activity modification advice
  • the use of an appropriate contoured pillow for sleeping
  • ergonomic advice
  • exercises to improve flexibility, strength (particularly of the deep cervical flexors), posture, core stability and neural mobility
  • clinical Pilates
  • hydrotherapy
  • a gradual return to activity program

Other intervention for neck whiplash

Despite appropriate physiotherapy management, a small percentage of patients with neck whiplash fail to improve and may require other intervention. This may include pharmaceutical intervention, corticosteroid injection, investigations such as an X-ray, CT scan or MRI, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.


Exercises for neck whiplash

The following exercises are commonly prescribed to patients with neck whiplash. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should only take place provided there is no increase in symptoms.


Initial Exercises

The following initial exercises should generally be performed 3 – 5 times daily and only provided they do not cause or increase symptoms.

Chin Tucks

Begin sitting or standing tall with your back and neck straight. Your shoulders should be back slightly (figure 6). Tuck your chin in as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Keep your eyes and nose facing forwards. Hold for 2 seconds and repeat 10 times provided the exercise does not cause or increase symptoms. Repeat 3 – 5 times daily.

Exercise for Neck Whiplash - Chin Tucks

Figure 6 – Chin Tucks

Shoulder Blade Squeezes

Begin sitting or standing tall with your back and neck straight (figure 7). Squeeze your shoulder blades together as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Hold for 5 seconds and repeat 10 times provided the exercise does not cause or increase symptoms. Repeat 3 – 5 times daily.

Exercises for Neck Whiplash - Shoulder Blade Squeezes

Figure 7 – Shoulder Blade Squeezes


Intermediate Exercises

The following intermediate exercises should generally be performed 2 – 3 times daily and only provided they do not cause or increase symptoms.

Neck Rotations

Begin sitting with your back and neck straight and your shoulders back slightly. Turn your head looking over one shoulder as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 8). Then repeat the exercise turning your neck in the opposite direction. Keep your neck straight and don’t allow your head to poke forwards during the movement. Repeat 10 times to each side provided the exercise does not cause or increase symptoms. Repeat 2 – 3 times daily.

Exercises for Neck Whiplash - Neck Rotations

Figure 8 – Neck Rotations (right side)

Side Bend in Sitting

Begin sitting tall with your back and neck straight, your shoulders should be back slightly. Gently bend your neck to one side as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 9). Repeat the exercise gently bending your neck to the other side. Make sure your neck does not bend forwards during the movement. Repeat 10 times on each side provided the exercise does not cause or increase symptoms. Repeat 2 – 3 times daily.

Side Bend in Sitting

Figure 9 – Side Bend in Sitting (right side)

Rotation Stretch with Chair

Begin sitting on an appropriate chair, side on, with your back and neck straight. Place your hands on the back of the chair, rotate your torso to one side as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Try to keep your legs, back and neck straight (figure 10). Hold for 2 – 5 seconds and repeat 10 times on each side (ideally alternating sides) at a mild to moderate stretch provided the exercise does not cause or increase symptoms. Repeat 2 – 3 times daily.

Rotation Stretch with Chair

Figure 10 – Rotation Stretch with Chair (left side)

Resistance Band Pull Backs

Begin this exercise in standing or kneeling with your back and neck straight and holding a resistance band as demonstrated (figure11). Slowly pull your arms backwards, squeezing your shoulder blades together as demonstrated. Hold for 2 seconds and perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Repeat twice daily.

Resistance Band Pull Backs

Figure 11 – Resistance Band Pull Backs


Advanced Exercises

The following advanced exercises should generally be performed 2 – 3 times daily and only provided they do not cause or increase symptoms.

Extension in Sitting

Begin sitting tall, with your back and neck straight, your shoulders should be back slightly. Gently take your neck backwards, looking up towards the ceiling as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 12). Repeat 10 times provided the exercise does not cause or increase symptoms. Perform 2 – 3 times daily.

Extension in Sitting

Figure 12 – Extension in Sitting

Flexion in Sitting

Begin sitting tall, with your neck and back straight, your shoulders should be back slightly. Gently bend your neck forwards, taking your chin towards your chest as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 13). Repeat 10 times provided the exercise does not cause or increase symptoms. Repeat 2 – 3 times daily.

Flexion in Sitting

Figure 13 – Flexion in Sitting

Extension over Towel

Begin lying on your back on a comfortable firm surface, such as carpet. Place a rolled towel under your upper back, with your arms across your chest (or by your side). Ensure the rolled towel is a size that is comfortable for you, enabling you to fully relax (figure 14). You should feel a mild to moderate stretch in your upper back without pain. Hold for 15 – 60 seconds, then move the towel up a level. Repeat along the length of your upper back. This exercise can then be progressed by placing your arms overhead or by increasing the size of the rolled towel, or, by progressing to a Foam Roller instead of a towel. A pillow may be required under the head for comfort. Repeat twice daily provided the exercise does not cause or increase symptoms.

Extension Over Towel

Figure 14 – Extension over Towel


Rehabilitation Protocol for neck whiplash

The following is a general rehabilitation protocol for patients with neck whiplash. This needs to be tailored to each individual and should be discussed with your treating physiotherapist prior to commencing. Progression through this program can vary from several days to many weeks depending on severity of injury and quality of treatment:

  • See your physiotherapist as soon as possible to confirm diagnosis, rule out serious injuries (such as spinal fractures) establish the likely prognosis, identify the contributing factors to injury and begin appropriate treatment.
  • Follow the R.I.C.E. Regimefor the first 48 – 72 hours following injury or if inflammatory signs are present (night-time ache / pain, morning ache / stiffness or pain at rest). This should primarily comprise:
    • Rest from any activity that increases pain, particularly sustained forward bending of the neck, such as reading books or using smart phones (try to look down with your eyes instead of your neck), slouching (especially during sleeping or sitting), activities using your arms in front of the body (e.g. washing dishes, driving etc.), excessive twisting of the neck and lifting (the use of a soft cervical collar, postural support, or postural taping for general activity or contoured pillow for sleep may be required). Take regular rest periods in positions of minimal stress for the neck such as lying or walking in optimal posture.
    • Ice the sore area for 20 minutes and repeat every 2 hours (using an ice pack wrapped in a damp tea towel)
    • Anti-inflammatory or pain relieving medication may be beneficial (this should be discussed with your doctor and/or pharmacist prior to use)
  • Avoid H.A.R.M. during the first 48 – 72 hours following injury or when inflammatory signs are present (night-time pain / ache, morning ache / stiffness or pain at rest) including:
    • Heat (avoid using heat on the injured area, this includes the use of heat packs, hot baths or spas)
    • Alcohol consumption
    • Rigorous Exercise of the affected body part
    • Massage
  • “Initial Exercises” can usually commence as soon as able provided they are comfortable and do not increase symptoms.
  • Settle symptoms – Aim to settle symptoms as quickly as possible by maintaining optimal posture (or as close to optimal posture as possible without increasing your symptoms) and avoiding aggravating activities (a soft cervical collar, postural support or postural taping may be required). Any activity that increases pain during the activity, or after the activity with rest should be avoided or minimised, particularly excessive:
    • Bending forwards of the neck
    • Slouching
    • Use of the arms in front of the body
    • Excessive twisting of the neck
    • Lifting
  • Whilst symptoms are acute, increase the time you spend lying down in optimal posture with an appropriate pillow and in a position of comfort (or as close to optimal posture as possible without increasing symptoms). Better positions usually include lying on your back with a contoured pillow that is an appropriate height (thinner pillows are usually better at encouraging optimal spinal alignment provided they are comfortable), lying on your back with a rolled up towel placed in the arch of your neck or no pillow are other options (these options are only appropriate if comfortable and provided they do not increase symptoms). Lying on your side is another good option. If lying on your side, it is important to lie as straight as possible (figure 5) and to avoid curling up into the fetal position (figure 2). A contoured pillow should be used that is an appropriate size to bridge the gap between your bed and neck and prevent your neck from tilting down to the bed (if the pillow is too thin) or away from the bed (if the pillow is too thick). A pillow may also be placed between your knees for comfort. Lying on your stomach is generally not recommended since it places considerable stress on your neck. This occurs since you have to turn your head almost 90 degrees to breath. If you have to sleep on your stomach, your posture can be improved by placing your head on the edge of the pillow, and only turning your head slightly to the side. This allows you to breathe whilst minimizing stress and rotation of the neck.
  • A Soft Cervical Collar, Postural Support or Postural Taping may be beneficial to reduce stress on the upper back and neck. These must be comfortable and must be removed if they result in an increase in symptoms.
  • Once symptoms settle, aim for pain free rehabilitation (i.e. gradually increase activity levels and progress exercises to improve strength, flexibility, posture, core stability and fitness, provided there is no increase in symptoms during activity or upon rest following activity (e.g. upon waking the next morning). This should take place over days to weeks depending on injury severity and with guidance from the treating physiotherapist). If using a posture support or posture tape, gradually reduce the duration of use as symptoms improve.
  • Maintain optimal posture at all times (or as close to optimal posture as possible without increasing your symptoms). Think tall, draw your shoulder blades back slightly, and tuck your chin in (figures 4 & 5).
  • When lying down or sleeping, use a contoured therapeutic pillow that is comfortable and an appropriate size for you, and ideally, sleep on your back or side in optimal posture. You should try to lie as straight as possible and comfortable. Ideally lie on your back with a contoured pillow supporting the arch of your neck (the pillow should generally be relatively thin provided it is comfortable and does not increase symptoms), a rolled up towel placed in the arch of your neck is another option or no pillow (these options are only appropriate if comfortable and provided they do not increase symptoms).
  • Avoid sustained posture – regularly change positions and avoid staying in the same postural position for long periods of time (e.g. reading magazines, newspapers or books, watching TV or a computer screen, or, driving for long periods). Ensure breaks are regular enough and long enough to prevent symptom exacerbation.
  • If Sitting, try to sit in optimal posture with a straight back and neck (in a straight back chair), and, with a lumbar support in the small of your back. Try to keep sitting periods to less than 20 minutes at a time and less than 2 – 3 hours total per day.
  • Heat treatment can usually commence 72 hours following injury provided there is no inflammation (i.e. night-time pain, morning ache/stiffness, or pain at rest). Apply a heat pack to the injured area (whilst maintaining optimal posture) at a comfortable warmth for 20 – 30 minutes before exercises or as frequently as desired. If there are still signs of inflammation continue to use ice instead of heat.
  • If using a soft cervical collar, Postural Support or Postural Taping, gradually reduced the duration of use over a number of days or weeks, once symptoms have settled, provided there is no increase in symptoms.
  • Progress to the “Intermediate Exercises” once the “Initial Exercises” can be performed comfortably for a few days consecutively. Ensure all new exercises do not cause or increase symptoms. The ‘Intermediate Exercises’ should be added to the ‘Initial Exercises’. Generally you should begin with one ‘Intermediate Exercise’ and gradually add the remaining ‘Intermediate Exercises’ after a number of days to weeks provided there is no increase in symptoms.
  • Progress to the “Advanced Exercises” once the “Intermediate Exercises” can be performed comfortably for a few days consecutively. Ensure all new exercises do not cause or increase symptoms. The ‘Advanced Exercises’ should be added to the ‘Initial and Intermediate Exercises’. Generally you should begin with one or two ‘Advanced Exercises’ and gradually add the remaining ‘Advanced Exercises’ over a number of days to weeks provided there is no increase in symptoms.
  • Do not increase activity levels too rapidly especially in the first 2 weeks beginning from when symptoms have settled. In this period, injury recurrences are common. Be particularly careful when returning to activities involving forward bending of the neck, using the arms in front of the body, slouching (especially during sitting / sleeping), and lifting activities. Ensure these activities are not too repetitive, prolonged or forceful.
  • Gradually build up cardiovascular activity beginning with gentle forms of exercise such as walking. This may be changed to other forms of training, if desired, or progressed by increasing the frequency, intensity or duration of training provided there is no increase in symptoms during activity or after activity with rest (e.g. the following morning). Better activities include: walking, jogging and use of a cross trainer or stationary exercise bike in good posture.
  • Clinical Pilates Exercises can help to improve core stability, posture and flexibility and can help to reduce the likelihood of symptom recurrence. These should generally be implemented provided there is no increase in symptoms.
  • Further Arm Strengthening Exercises, Leg Strengthening Exercises, Core Stability Exercises, Upper Body Gym Exercises, Lower Body Gym Exercises, Arm Stretches and Leg Stretches may be added to improve general strength, flexibility, core stability and activity tolerance of the neck. These exercises should be implemented gradually and provided there is no increase in symptoms. Your treating physiotherapist can advise which exercises are most appropriate for you and when they can commence.
  • If working in an office, ensure your desk and computer setups are ergonomically sound (see Ergonomic Computer Setup).
  • If using a mobile phone, ensure your use is as ergonomically sound as possible (see Mobile Phone Ergonomics)
  • A gradual return to activity should occur provided there is no increase in symptoms.
  • Ensure your physiotherapist has identified any factors that may perpetuate your injury and appropriate intervention has taken place to address these issues to minimize the likelihood of injury recurrence.
  • Maintain healthy neck habits – such as maintaining good posture, following correct lifting technique and practices, avoid slouching or sitting for long periods of time, use an appropriate contoured pillow for sleeping, ensure your environment is as ergonomically sound as possible, maintain a healthy body weight, hydration levels and diet, and perform regular exercise.

Physiotherapy Products for neck whiplash Physiotherapy products for neck whiplash

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:

  1. Postural Supports
  2. Therapeutic Pillows
  3. Ice Packs or Heat Packs
  4. Lumbar Supports for Sitting
  5. Sports Tape (for postural taping)
  6. McKenzie Cervical Rolls (for sleeping)
  7. McKenzie Treat Your Own Neck Books
  8. TENS Machines (for pain relief)
  9. Foam Rollers (for upper back stretches and Pilates exercises)
  10. Resistance Band (for postural strengthening and Pilates exercises)
  11. Cervical collars

To purchase physiotherapy products for neck whiplash click on one of the above links or visit the PhysioAdvisor Shop.


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