Your Guide to Whiplash Recovery in the first 12 weeks after the accident 2nd Edition 2007
Your Guide to Whiplash Recovery in the first 12 weeks after the accident Adapted from: Your guide to whiplash recovery in the first 12 weeks after the accident January 2001 published by the MAA Whiplash injury recovery a self-management guide by Professor Gwendolen Jull (2005), The University of Queensland, published by the Motor Accident Insurance Commission (MAIC)
Contents What is whiplash?.......................................................... 1 What is WAD (Whiplash-Associated Disorders)?................... 2 When should I seek medical advice?................................. 3 How is WAD treated?...................................................... 4 How long will it take me to get better?............................... 5 What can I do to help me get better?................................. 6 Treatments.................................................................... 9 Treatments that are recommended........................................ 9 Treatments that may help.................................................... 9 Treatments that are not recommended.................................. 11 Exercises that will help.................................................... 13 Where else can I get help?............................................. 22 Other publications......................................................... 23
What is whiplash? Whiplash is what happens when someone s head moves forwards and then backwards quickly. This quick back and forth movement may cause injury to the neck. This whiplash movement often happens in car crashes. People who have been in a crash often complain of neck pain and stiffness afterwards, sometimes not until a few days after the accident. For most people the pain is mild, does not interfere with their normal activities and gradually gets better. However, for some people recovery is slower especially if the injury is more severe. Research indicates that people who carry on with their normal activities recover faster than people who stay at home and reduce their activities. Neck pain is the most common symptom associated with a whiplash injury. However, some people have more severe neck pain than others. People with whiplash may also experience: headaches pain in the shoulders and arms dizziness or altered sensation, for example, pins and needles weakness in the arms. These people should see a doctor immediately since they may have a Whiplash-Associated Disorder, or WAD as it also known. 1
What is WAD? The term WAD stands for Whiplash-Associated Disorders. It covers a range of neck problems resulting from the whiplash motion of the accident. These can range from no discomfort at all to very severe injuries. To help the doctor work out how serious your injury is and the most appropriate treatment, the neck problems from a whiplash have been grouped into four grades of WAD. Whiplash-Associated Disorders (WAD) Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 No pain or discomfort. No physical signs of injury. Neck pain, stiffness or tenderness. No physical signs of injury. Neck pain, stiffness or tenderness and some physical signs of injury such as point tenderness or trouble turning the head. Pain, stiffness or tenderness and neurological signs of injury, such as changes to reflexes or weakness in the arms. Pain and fracture or dislocation of the neck. 2
When should I seek medical advice? You should seek medical advice after an accident if you have: medium to severe pain in your neck neck pain plus stiffness (you have problems turning your head) arm numbness or weakness drowsiness, nausea, vomiting, confusion any complaints that are not getting better or are getting worse. These symptoms may mean you have WAD. It is important that you see your GP for a medical assessment. A registered health professional such as your GP, physiotherapist or chiropractor is the best person to advise you about how to manage your WAD. They may also ask you to fill in some questionnaires to help them work with you to treat your injury. It is also important that you tell your GP of other health professionals who may be treating you. 3
How is WAD treated? Your doctor will provide you with information, advice and the recommended treatment. If your pain is mild, your doctor will advise you to continue normal daily activities and, if required, use pain-relieving medication such as paracetamol. If you have more severe pain, you may be advised to continue with light activities, use pain relieving medication and do exercises. The exercises will help to restore movement and flexibility in your neck, and ensure that your muscles are acting to support the neck. Examples of exercises are shown on pages 13 to 21. In many cases your doctor will ask that you return to check your progress, usually within a week of your first visit. Your return visit is important. In some cases (especially if there is no improvement) your doctor will send you for additional treatment. Many treatments have been used for WAD in the first 12 weeks after an accident. A Working Party of experts in this area has reviewed these treatments and grouped them into three categories: Recommended treatments; Treatments that may help (not routinely recommended); Treatments that are not recommended. More information on treatment is found on pages 9 to 12. 4
How long will it take me to get better? Most people will be able to continue with their normal activities, but it may take weeks, or months, for the discomfort to go away completely. An active recovery in which you continue your normal activities is the best way to recover. If you have had to reduce your normal activities, you should be able to return to them within weeks. Pain is a normal reaction to being hurt. Pain during the recovery period does not necessarily mean that further injury has occurred. It may seem that it is taking a long time for you to recover. If you are worried about this, or if your pain gets worse, see your doctor. Your doctor may decide you need an assessment by a specialist. The aim of assessment and treatment is to relieve pain and restore function, and to identify factors that may be associated with slower recovery. A positive approach is needed, but for many people with whiplash it is not possible to abolish all symptoms in the 12 week time frame covered by these Guidelines. Most people recover completely from a WAD although some take longer than others. Every injury is different. 5
What can I do to help me get better? Gently exercise your neck to restore movement and flexibility and to ensure that the muscles are acting to support your neck. Examples of exercises are shown on pages 13 to 21. Try to stay active. Do as many of your normal activities as possible. Staying active helps you to recover more quickly. Relaxing both body and mind will help you manage any pain more easily. Remember lessen the strain and have less pain. Stay at work if you can. People who stay at work after an accident recover more quickly than those who take time off. Don t use a collar without advice from your doctor or therapist. Most people don t need to use collars, and using one may unnecessarily slow your recovery. Managing yourself is important in the early stages of a whiplash injury. Here are some handy hints for performing your daily activities at work, at home and at leisure. Work activities Think about your work and work loads to avoid unnecessary strain on your neck. Initially avoid heavy lifting. When sitting, change your posture regularly and perform some of the gentle exercises as shown on page 16. The chair you sit on at work may need adjusting. On page 8 is an example of how to make sure you are in the correct posture at work (Figure 1). Stand up for a break at regular intervals or change position every 20 minutes. 6
What can I do to help me get better? Home activities Divide heavy loads (e.g., grocery shopping) into several lighter loads for carrying. Spread the tasks out and rotate them. For example, do household chores over a few days rather than all at once. Bring the task closer to you. For example, lower the clothes line to reduce the strain on your shoulders and neck while hanging out the clothes, or kneel to weed the garden. When trimming high hedges, don t stretch up too high. Consider using a stepladder to improve your position but make sure it is positioned safely. Use a wheelbarrow to take weeds to the compost bin. In the laundry, lift fewer clothes from the washing machine at once. Leisure activities Think about where and how you are sitting at the movies. Choose a seat in the centre of the theatre. By sitting straight on you can reduce neck strain and enjoy the movie. At a dinner party sit so that you can view people straight on. Sitting with your head turned to talk for prolonged periods can make it stiff. Avoid extreme prolonged postures of the neck. For example, at the hairdressers, if it hurts your neck to sit at the basin, stand and face the basin instead. When reversing your car, rotate your body to look behind you rather than only rotating your neck. When watching TV, practice your postural exercises during the advertisements. Try not to sit for too long. 7
When returning to sport, consider reducing the level of difficulty and the time spent doing the activity. For example, when swimming, swim fewer laps. Figure 1: Correct sitting posture at work Assess how you spend your day at work Whether it is in a motor vehicle or at a desk/computer terminal, you need to give your body a change of position throughout the day. Take a neck break. It can be as simple as standing up for a few moments to straighten your spine or stretch backwards gently. Arrange your desk, computer and chair to avoid strain on your neck. A B C D Position your screen slightly below eye level and directly in front of you. Have an adjustable chair so that you can change the height and back support. Sit with hips, knees and elbows at close to 90 degree angles. Feet flat on floor or foot stool. Document holder should be at the same eye level as the screen and close to the monitor. Use a headset if your job entails extensive use of a telephone. Reprinted with permission from Jull G, The University of Queensland 8
Treatments Treatments that are recommended Act as usual Pain is a normal reaction to being hurt. You may have pain but maintaining your normal activities is an important factor in getting better. Exercise Specific exercises to restore muscle control and support your neck should improve postural control and prevent unnecessary postural strain. Exercises that may help you are on pages 13 to 21. General exercise (such as walking) and activity are also important. Pain relieving medication Pain relieving medication such as paracetamol can be prescribed. Treatments that may help These treatments are not routinely recommended, but may be used, especially if you are not improving. Advice about posture Advice about how to sit and stand correctly can be helpful in addition to maintaining usual activities and exercising. The correct way to sit at your computer is on page 8. 9
Passive joint mobilisation A therapist gently and repetitively moves the joints in the neck region to reduce pain and restore normal movement in the neck. This can be used if it reduces your symptoms. It is important that your therapist is registered, qualified and trained to do mobilisation. Spinal manipulation A therapist applies a gentle quick single thrust to the joint to the limit of its range of movement. This produces a clicking sound. The manipulation aims to reduce pain and restore motion. It can be used if it reduces your symptoms. You should check that your health provider (medical practitioner, chiropractor, osteopath or physiotherapist) is registered, qualified and trained to do manipulation. Combination of treatments A combination of treatments such as exercise and passive joint mobilisation can be used. Anti-inflammatory medication For more severe cases, anti-inflammatories can be prescribed by your doctor in the short term to reduce pain and swelling. Use of this form of medication should be limited as it may have side effects. Traction A machine gently stretches the neck. Traction can be used with other treatments. There is no evidence that traction works for WAD, so it should only be used if it reduces your symptoms. 10
Treatments Acupuncture Fine needles are inserted into specific points on the body. There is no evidence that acupuncture works for WAD; it should only be used if it reduces your symptoms. Transcutaneous Electrical Nerve Stimulation (TENS), heat, ice, massage, ultrasound, laser, short-wave diathermy TENS is a low frequency, painless electric current sent through the skin to reduce pain. These passive treatments/electrotherapies, if administered by trained professionals, are additional treatment options during the first three weeks. They are used with manual and physical therapies and exercise to help you return as soon as possible to your usual activity. Surgical treatment Surgery is not required in almost all cases of WAD Grades 1 to 3. Treatments that are not recommended Cervical pillows The use of commercially-made contoured pillows is not recommended as there is no evidence to prove their usefulness. Bed rest A period of bed rest is not recommended for people with WAD Grade 1. People with WAD Grades 2 and 3 should not have bed rest for more than four days. 11
Collars The use of a collar, sometimes called a neck brace, should not be prescribed for WAD. If they are prescribed, they should not be used for more than 48 hours. Spray and stretch Spraying the muscle with a cold spray followed by muscle stretching is not recommended. There is no evidence this technique works. Steroid injections Injecting steroids are not recommended for WAD Grades 1 and 2. Steroid injections may be used for WAD Grade 3. Repeated steroid injections may cause harm. Injections of local anaesthetic or sterile water The injection of local anaesthetic or sterile water into nearby nerves is not recommended in the early stages of WAD. Magnetic necklaces Wearing a magnetic necklace is not recommended. There is no evidence to prove their usefulness. Pilates, Feldenkrais, Alexander Technique, massage and homeopathy These techniques are not recommended for the first 12 weeks. There is no evidence to show they work during this period. 12
Exercises that will help The following exercises should help to heal your neck. Perform all exercises in a slow and controlled manner. The exercises are designed to restore the movement and muscle control around your neck and to reduce unnecessary postural strain and muscle pain. When you are performing the exercises, stop and contact your doctor or therapist if you notice: dizziness, light headedness, blurred vision, fainting or disorientation sudden pain shooting down your arm, or numbness or weakness in your arm or hand unusually severe neck pain exercises consistently producing a headache, which persists. For each exercise: move smoothly and slowly, without sudden jerks. The key is precision and control. keep your mouth and jaw relaxed. Keep lips together, teeth slightly apart and let your tongue rest on the roof of your mouth. gently hold your shoulders back and down so that they are relaxed while doing all exercises (see posture correction exercise, exercise 4). 13
in movement exercises, try to move the same distance to each side. If one side is stiffer, move gently into the stiffness. Move to that direction a little more often. expect some discomfort, but remember exercises should not cause severe pain. Neck exercises lying down Lie down with a soft pillow under your neck, and with your knees bent up. 1. The chin nod exercise 1 Gently and slowly nod your head forward as if to say yes. Feel the muscles at the front of your neck. Stop the nodding action just before you feel the front muscles hardening. Hold the nod position for five seconds and then relax. Gently move your head back to the normal start position. Repeat up to 10 times. 1. Jull GA The management of cervical headache. Manual Therapy 1997 2(4):182-190 14
Exercises that will help 2. Head rotation Gently turn your head from one side to the other. Look where you are going. Progressively aim to turn your head far enough so your chin is in line with your shoulder and you can see the wall in line with your shoulder. Repeat 10 times to each side. 3. Shoulder blade exercise This exercise will relax and ease any tension in the muscles on top of your shoulders. It will give you pain relief. A Lie on your right side with your arm resting up on two pillows. B Roll your left shoulder blade back and across your ribs towards the centre of your back. Hold the position for 10 seconds. Repeat 5 times. A B Repeat lying on the left side for the right shoulder blade. 15
Exercises while sitting 4. Correct postural position Correct your posture regularly by gently straightening up your lower back and pelvis (sit tall). Now gently draw your shoulder blades back and down (women towards their bra clip). Gently tuck your chin in. Hold the position with ease for at least 10 seconds. This position will prevent and ease muscle pain and tension in your neck and shoulder muscles. Repeat the correction regularly, every half hour during the day. You can do this exercise at work, in the car, train or bus and sitting at home. 16
Exercises that will help 5. Neck retraction A Sit in the correct postural position as shown in exercise 4 above. B Gently draw your head back, sliding your chin back horizontally and keeping your nose pointing straight ahead. You should feel the retraction movement at the base of your neck and your neck should stay long. Repeat this 10 times every hour when sitting. A B Neck movement exercises Sit in the correct postural position as described in exercise 4. Repeat all exercises below 10 times to each side. 6. Rotation Gently turn your head from one side to the other. Look where you are going, progressively aim to see the wall in line with your shoulder. This exercise is similar to the one you did lying down. This time you do it sitting. 17
7. Side bending Gently tilt your head towards your shoulder and feel the gentle stretch in the muscles on the side of your neck. Perform the movement to both sides. 8. Bending and extension Gently bend your head towards your chest. Lead the movement with your chin. Moving the chin first, bring your head back to the upright position and gently roll it back to look up towards the ceiling. Leading with your chin, return your head to the upright position. 18
Exercises that will help Neck strengthening exercises (Exercises 9-11) should only be started later in your recovery. If unsure when to begin this, ask your treating health professional. 9. Neck strengthening exercises (isometric, no movement exercise) Sit in the correct postural position as described in exercise 4. Make sure your chin is relaxed and slightly down. Place your right hand on your right cheek. Gently try to turn your head into your fingers to look over your right shoulder but allow no movement. Hold the contraction for five seconds. Use 10% to 20% effort, no more! Repeat with the left hand on the left cheek. Do five repetitions of the holding exercise to each side. 19
Neck strengthening exercises whilst 4-point kneeling Firstly, adopt the 4-point kneeling position. Begin by ensuring your knees are directly under your hips, and your hands under your shoulders. Your low back should be in a neutral position that is, with a natural arch. Gently draw your belly button to your spine (10% effort). Push gently through your shoulder blades, so that your upper back is level. Draw your shoulders gently away from your ears, or toward your hips. Lift your head up so that it is level with your shoulders, but maintaining a gentle chin tucked or nod position. Once you can hold the safe 4-point kneeling position, then proceed with the neck movement exercises as described below: 10. Neck bending and extension in 4-point kneeling A Adopt the safe 4-point kneeling position. B Slowly look up toward the ceiling as far as you can go. Hold for 5-10 seconds. C Follow this by slowly bending your neck, leading the movement with a chin tuck or nodding action. Continue the neck bending movement as far as possible, aim for your chin to touch your chest. Throughout this movement you should hold the neutral lower back and shoulder blade posture described above. Perform 5-10 repetitions. A B C 20
Exercises that will help 11. Neck rotation in 4-point kneeling Adopt the safe 4-point kneeling position. Slowly rotate (turn your neck to one side). It is important to maintain the gentle chin tuck or nod position throughout the movement. Also, make sure your head stays level with your body, and does not drop down. If you do this exercise correctly, you should be looking over your shoulder at the end of the movement. It helps to do this exercise side on to a mirror so that you can check your head position. Repeat to the other side. Perform 5-10 repetitions. 21
Where else can I get help? Specialist health professionals Your GP can refer you to health professionals who are experts in treating WAD. These may include a GP who sees a lot of WAD patients, medical specialists, physiotherapists and chiropractors. Pain management clinics You would normally be sent to a pain management clinic only if your injury and/or pain is severe and long lasting. Community resources Evening and community colleges run classes in relaxation and stress management, but see your doctor before starting one of these. For the phone number of your nearest college look under Evening & Community Colleges in the phone book. Local hospitals may also run relaxation classes. Website The MAA website www.maa.nsw.gov.au has general information on rehabilitation and other publications on Whiplash-Associated Disorders. Claims Advisory Service For information or assistance on a CTP claim contact the Motor Accidents Authority Claims Advisory Service on 1300 656 919. 22
Other publications This guide is meant for people injured in motor vehicle accidents and for their friends and family. The MAA also publishes technical guidelines for health professionals involved in the treatment of WAD and for CTP insurance companies. Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007 Summary Guidelines for the Management of Acute Whiplash-Associated Disorders for Health Professionals 2nd Edition 2007 Compulsory Third Party Claims Guide for the Management of Acute Whiplash-Associated Disorders An Insurer s Guide 2nd Edition 2007 Technical Report: Guidelines for the Management of Acute Whiplash- Associated Disorders 2nd Edition 2007 For copies, please contact the MAA on 1300 137 131 23
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IP10633 For more information If you have queries contact: Motor Accidents Authority Level 25, 580 George Street SYDNEY 2000 Phone: 1300 137 131 Fax: 1300 137 707 Website: www.maa.nsw.gov.au Email: rehab@maa.nsw.gov.au Claims Advisory Service: 1300 656 919 Motor Accidents Authority NSW, 2007. You may copy, distribute, display and otherwise freely deal with this work for any purpose, provided that you attribute the Authority as the owner. However, you must obtain permission if you wish to (1) charge others for access to the work (other than at cost), (2) include the work in advertising or a product for sale, or (3) modify the work. ISBN 978-1-921422-04-1