Changes

November 2023 — reviewed. A literature search was conducted in November 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Some minor structural changes have been made, including the addition of short sections on prevalence, causes and complications, but no major changes to the recommendations.

Update

Goals

To support primary healthcare professionals to:

• Make an accurate diagnosis of whiplash injury.
• Make an accurate assessment of the severity of the illness, and refer urgently if serious injury is suspected.
• Treat appropriately in primary care.
• Provide appropriate advice and follow-up when required.
• Refer to secondary care or other specialist services when required.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

​​​​​​Non-steroidal anti-inflammatory drugs (NSAIDs):

• Regularly review the appropriateness of NSAID prescribing, particularly in older people and/or those at higher risk of gastrointestinal (GI), cardiovascular or renal morbidity and mortality.
• Consider switching to a lower-risk NSAID or stopping treatment where appropriate.
• Consider alternatives to oral NSAIDs, such as topical NSAIDs, physiotherapy or a different analgesic, such as paracetamol or an opioid, before prescribing NSAIDs.
• When prescribing NSAIDs, choose those with the lowest cardiovascular, renal and/or GI risk, depending upon the individual person's risk factors.
• If more than one product is suitable, choose the product with the lowest acquisition cost. 
• Do not prescribe NSAIDs when contraindicated, and only prescribe NSAIDs to people at risk of renal impairment or failure when use is unavoidable.
• Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms.
• Ibuprofen (1,200 mg a day or less) or naproxen (1,000 mg a day or less) are generally preferred for safety reasons.
• Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis or rheumatoid arthritis, those who are elderly, those with lower back pain, axial spondyloarthritis, psoriatic arthritis or other peripheral spondyloarthritides, and those at moderate or high risk for GI adverse effects.

[PrescQIPP, 2020]

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• An acute whiplash injury follows sudden or excessive hyperextension, hyperflexion, compression, or rotation of the neck and causes neck pain and other symptoms.
• The Quebec Task Force on Whiplash-Associated Disorders defined whiplash as 'an acceleration-deceleration mechanism of energy transfer to the neck'.

[Spitzer, 1995; Tanaka, 2018; Godek, 2020; BMJ Best Practice, 2022b]

How common is it?

• Accurate measures of the incidence and prevalence of whiplash injury are difficult to produce due to variations in the proportion of people who seek medical attention after injury and the possible underreporting of symptoms.
• Estimates indicate that 300-600 per 100,000 people in North America and Western Europe experience whiplash injuries each year.

[Cassidy, 2000; Holm, 2008] 

What causes it?

• Whiplash most typically occurs as a result of rear-end or side-impact motor vehicle collisions but can also result from sports injuries, physical abuse, or other trauma.
• The impact may result in bony or soft-tissue injuries (whiplash injury), which may lead to a variety of clinical manifestations called whiplash-associated disorders (WAD).
• Symptoms may be very severe despite no specific abnormality being found in detailed clinical or radiological investigation. Soft-tissue injury is the most likely explanation.

[Tanaka, 2018; Godek, 2020; BMJ Best Practice, 2022b]

What is the prognosis?

• There is uncertainty about the prognosis for people with whiplash-associated disorders (WAD), although it is known that personal and societal factors have a large impact on the course of recovery.
• However, there is evidence that: 
  • High initial pain intensity or high frequency of health care utilisation in the first weeks after injury is associated with persistent neck pain and disability.
  • There is a positive correlation between post-traumatic stress symptoms and outcomes.
  • Negative expectations of recovery are associated with ongoing neck pain and disability.
  • Self-rated collision severity may be predictive of poor recovery. 
  • Decreased initial neck range of motion and initial cold hyperalgesia are predictive of ongoing disability.
  • Experiencing pain-related depression or kinesiophobia is associated with poor recovery.
• In at least 40% of people, there should be some resolution of symptoms by 6 weeks; there should be substantial improvement in 50% of people by 12 weeks and complete resolution in at least 40% of people. 
• Approximately 50% of people will fully recover within 6 months, but 50% may continue to experience symptoms up to 1 year post-injury. However, this may be highly dependent on the definition of recovery. 
• The risk of chronic pain developing after a whiplash injury is estimated at 20-40%.

[NSW Government, 2014; APTA, 2017; Al-Khazali, 2020; Godek, 2020; Shearer, 2020; Andersen, 2022]

What are the complications?

• Whiplash-associated disorders can impair activities of daily living and may also cause substantial socio-economic problems where the condition limits a person's ability to work.
• Depression may occur as a comorbidity in people with whiplash or whiplash-associated disorders (WAD). If identified, depression should be managed appropriately. See the CKS topics on Depression in children and Depression for more information.
• Post-traumatic stress symptoms may occur following a traumatic injury. Where identified, post-traumatic stress disorder (PTSD) could develop and should be managed appropriately. See the CKS topic on Post-traumatic stress disorder for more information.

[NSW Government, 2014; Shearer, 2020; Peolsson, 2021]

How should I assess someone with suspected whiplash injury?

In people with neck pain following sudden extension, flexion or rotation of the neck:

• Take a detailed medical history, ask about:
  • The circumstances of the injury (type of collision).
  • The symptoms: localisation, time and profile of onset, intensity of pain (ideally assessed using the Visual Analogue Scale [VAS]).
  • Occupational history.
  • Medical history, including previous injury or infection. 
  • Symptoms of anxiety or depression.
  • Previous injury or infection.
  • History of cancer — in these people, aetiology of pain should be assumed to be cancer until it is excluded.
  • Presence of fever — in these people, neck pain should be assumed to be secondary to an infection until proven otherwise.
• Do not examine neck movements until clinical features which may indicate a serious injury have been excluded.
  • If a serious neck or head injury is suspected, urgently refer to Accident and Emergency.
• Apply the Canadian C-spine rule in people aged 65 years or under to determine whether an X-ray of the cervical spine is required for diagnosis of fracture or dislocation:
  • Refer people at high risk of serious injury for cervical spine imaging. 
  • Assess active range of motion in people with any 1 of 5 low-risk characteristics for serious cervical injury. These include:
    • Simple rear-end motor vehicle collision.
    • Sitting position in the emergency department.
    • Ambulatory at any time.
    • Delayed onset of neck pain (not immediate onset of neck pain).
    • Absence of midline cervical spine tenderness.
  • People who are able to actively rotate their neck 45 degrees to the left and to the right, regardless of pain, do not require cervical spine radiography.
• Suspect a serious neck injury if the person cannot laterally rotate the neck more than 45 degrees.
• In the absence of clinical features which may indicate a serious injury, cervical X-rays and other imaging studies and investigations are not routinely required, as pathological signs of whiplash are rarely detected.
• Assess disability using the Neck Disability Index (NDI). 
• Evaluate for evidence of neurological involvement (for example, decrease in sensation, strength, or abnormal reflexes). For more information, see the section on Assessment in the CKS topic on Neck pain - cervical radiculopathy. 
• Consider examining for Kernig's sign (painful/resisted extension of leg bent at hip and knee) and Brudzinski's sign (reflective flexion of the knees when the patient is on his/her back and the neck is bent forwards) to demonstrate nuchal rigidity if meningitis is suspected.
• Palpate the neck for tenderness.
• Inspect the skin — for example, for papulovesicular rash, petechiae or purpura.
• Assess any associated injuries.
• Exclude other causes of neck pain.
• Classify the whiplash-associated disorders (WAD) grade using the Quebec Task Force Classification (see below).​
• Assess psychological state if appropriate. 
  • Ask about the person's expectation of recovery by asking if they think they are going to get better soon. If the patient has a negative response, they should be monitored and if improvement/recovery does not occur by three to six weeks, consider referral to a clinician with expertise in the management of WAD.

Quebec Task Force Classification of whiplash-associated disorders:

• Whiplash-associated disorders (WAD) can be classified into four grades: 
  • I  — neck pain and associated symptoms in the absence of objective physical signs.
  • II — neck pain and associated symptoms in the presence of objective physical signs and without evidence of neurological involvement.
  • III — neck pain and associated symptoms with evidence of neurological involvement, including decreased or absent reflexes, decreased or limited sensation, or muscular weakness.
  • IV — neck pain and associated symptoms with evidence of fracture or dislocation.

What are the signs and symptoms of whiplash?

• The most common symptoms of whiplash are: 
  • Neck pain, which may be referred to the shoulder or arm (84-100% of people).
  • Headache (60-83% of people).
    • Headaches following whiplash injury are typically occipital, short-lasting (1-7 hours maximum duration) and low-intensity (severe headache experienced in approximately 15%).
• Other signs and symptoms of whiplash may include: 
  • A reduced range of neck movements.
  • Muscular spasm.
  • Stiffness.
  • Deafness. 
  • Dysphagia or nausea. 
  • Sleep disturbance, fatigue, dizziness, or paraesthesia (less common).
  • Memory loss, impaired concentration or behavioural changes. 
  • Temporomandibular joint pain.
  • Tinnitus.
  • Visual disturbances, including blurred vision, reduced visual field and photophobia.

What else could it be?

• The differential diagnosis of neck pain is broad but includes trauma and non-musculoskeletal disease processes that can be classified as neoplastic, inflammatory, infectious, vascular, endocrinological, or neurological. For example: 
  • Acute disc prolapse — the most common cause of severe secondary torticollis.
  • Acute torticollis — neck pain that is due to acute spasm with no obvious underlying cause. For more information, see the CKS topic on Neck pain - acute torticollis.
  • Adverse drug reactions (for example, antipsychotic drugs, metoclopramide, amphetamines, cocaine).
  • Cervical facet syndrome.
  • Cervical strain/fracture/dislocation/myelopathy.
  • Cervical radiculopathy — for more information, see the CKS topic on Neck pain - cervical radiculopathy. 
  • Fibromyalgia. 
  • Infections (for example, herpes zoster, osteomyelitis).
  • Malignancy (for example, bony metastases)
  • Non-specific neck pain — neck pain that varies with different physical activities and with time, or is related to an awkward movement, poor posture, or overuse. For more information, see the CKS topic on Neck pain - non-specific. 
  • Neurological disorders (for example, due to peripheral neuropathy).
  • Osteoarthritis — for more information, see the CKS topic on Osteoarthritis.
  • Psychogenic dystonia and genetic conditions or disorders leading to dystonia (for example, Huntington's disease or primary torsion dystonia).
  • Rheumatoid arthritis — for more information, see the CKS topic on Rheumatoid arthritis. 

Scenario: Whiplash injury

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of acute whiplash injury.

Search dates

October 2018 - November 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 17th October 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCO MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4 S1 OR S2 OR S3

S3 AB ( (cervical OR neck) N2 sprain* ) OR TI ( (cervical OR neck) N2 sprain* )

S2 TI whiplash* OR AB whiplash*

S1 (MH "Whiplash Injuries")

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.