Medical Journal of the Mexican Social Security

Institute

ISSN: 0443-5117
revista.medica@imss.gob.mx
Mexican Social Security Institute Mexico

Ramírez González, Susana; Chaparro Ruiz, Ezequiel Salvador; de la Rosa Alvarado,

María del Rocío; Diaz Vega, Manuel; Guzman Gonzalez, Juan Manuel; Alcantara Jimenez, Jose
Alfredo Jimenez Alcantara; Lopez Roldan, Veronica Myriam; Rosas
Medina, Julio
rehabilitation clinic for patients with cervical sprain, guide on the first level
of attention
Medical Journal of the Mexican Social Security Institute, vol. 43, no. 1 2005, pp. 61-68
Mexican Social Security Institute
Federal District, Mexico

Available at: http://www.redalyc.org/articulo.oa?id=457745540009

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First version: June 8, 2004 Final
Version: July 4, 2004 Accepted: August
17, 2004
Susana Gonzalez
Ramirez, 1

Ezequiel Ruiz Salvador

Chaparro, 2
Clinical guide María del Rocío de la

for the rehabilitation of patients with cervical Rosa Alvarado, 3

Manuel Diaz Vega, 4

sprain, at the primary care level Juan Manuel
González Guzmán, 5

José Alfredo
Jimenez Alcantara, 6

Myriam Verónica
López Roldán, 7
SUMMARY SUMMARY
July Rosas Medina 1
The whiplash injury is a ligamentous stretching the Whiplash is a sprain of the ligament strain of the
muscles of the cervical spine for acceleration mechanism paraspinal With muscles due to acceleration or 1 Emergency Hospital
and disadvantages acceleration energy transmitted to the acceleration of energy transmitted back to the neck. The
Traumatology "Dr. Jose
neck. CLI- solely neck pain, neck stiffness, muscle symptoms are neck pain, neck stiffness, muscle spasm
Manuel Ortega
spasm and aggregates symptoms, affecting work and a multitude of discomforts That Affect job-related and
Dominguez "
activities and daily life of the patient presents. The activities of daily living. In 2000, the Mexican Social secu- 2 Medicine Unit
incidence of cervical sprain that occurred in 2000 in the rity System more than 15 000 Treated cases of whiplash
Family Room 1, National
Mexican Social Security Institute, was more than 15 due to job-related activities. With This information, we
Medical Center
thousand cases were classified as accidents. On this organized an expert team in order to Develop guidelines
XXI century
basis a clinical guide rehabilitation of patients with using methodology of evidence-based medicine and with a 3 Unit of Physical Medicine and
cervical esguin- ce, addressed to the family doctor, who focus on early treatment prescribed by generally the
rehabilitation Region
determined Bera promptly implement the practitioner in order for the patient to Obtain quick relief
Center
recommendations of the guide was developed, and to return the patient to His job and to His daily living 4 Health Coordination
activities as soon as possible.
at work
5 Care Coordination

6 Orthopedic Hospital
Lomas Verdes and
Traumatology
7 Regional Hospital 72

Mexican Social
Introduction General purpose Security Institute

The whiplash injury is a ligamentous stretching the timely reincorporate the patient with cervical is- guince
Communication with:
muscles of the cervical spine by a mechanism of their activities of daily life and work through Juan Manuel
acceleration and deceleration of energy transmitted to
rehabilitation treatment pro- portioned on the first level Guzmán González. Tel
the neck. 1-5
of care. .: 5726 1767 E-mail:
Clinical data presented are neck pain, limited jmguzman@avantel.net
neck mobility (stiffness), snapping sensation, muscle
spasm or "contracture". 4,6-10 Its incidence was cal- cula Specific objectives
in more than one million cases annually in the United
States; Women are affected in 70% and the age
Reduce disability time. Avoid complications and
group involved in greater proportion is 20 to 40 years. eleven
sequelae. timely referral to another ni- vel care, if
necessary. Keywords
Whiplash
In Mexico, in 2000 Ron REGISTERS at the Mexican rehabilitation
Institute of Social Security more than 15 thousand cases
of work accidents CLA- fied in the heading of
Users guide Key words
dislocations, lacerations and sprains neck. 12
Whiplash
family physician, rehabilitation, physical therapist. rehabilitation

Rev Med IMSS 2005; 43 (1): 61-68 61

 Susana white population
Gonzalez Ramirez
et al.
Whiplash adults with grade I or II, atendi- two on the
guide rehabilitation
first level of attention Mexicano Social Security Institute.
clinic Whiplash
operational definitions
whiplash or whiplash (whiplash) or forced
flexoextension syndrome: ligament injury with
stretching the muscles of the cervical spine due to
acceleration and deceleration mechanism of energy
that is transmitted gives the neck. 1,2,7,10,13
Whiplash associated disorders: It is presented in
16-44% of cases and manifest as headache,
vertigo, dizziness, dysphagia, sore jaw, shoulder or
back. 1,4,6,9,14-16
Remission Whiplash: Remi sion considered the absence
of clinical symptoms and nasal mucus.
systemization: clinical picture of compressibility root
sion involving the myotome, dermatoma and
osteoarticular reflex.
Identification and selection of
data
Search keywords were neck sprain injury, whiplash,
whiplash injury, whiplash, neck disorders, sources of
information dating from 1995 to July 2002. The
database was consulted Cochrane Library; They were
included for the construction of this guide five
systemized clinical reviews, one stage protocol. the
Medline database for finding clinical trials pu- blicados
was used after the date of systematized clinical review
and three RCTs and other aggregates items were
considered, regardless of their methodology. biblio-
graphy basic and clinical guidelines available practice
in different electronic pages are included.
The material found was analyzed by the team
builder guidance and eventual inclusion was
conducted by discussion among participants, using
the criteria of the guidelines for users of medical
literature publication two JAMA between 1993 and
2000 .
For the classification of the category of evi- dence and
strength of recommendations, utili-

table I
Classification level of evidence and strength of recommendation on the contents of these guidelines *

Evidence category Strength of recommendation

Ia. Evidence for meta-analysis A. Direct evidence based category I

Ib randomized clinical trials. Evidence of

at least
IIa clinical trial randomized controlled. Evidence of

at least B. Direct evidence based

a non-randomized controlled study category II evidence or extrapolated recommendations of
category I
IIb. At least one other type of study
Quasi-experimental or cohort study

III. Evidence of a descriptive study C. Direct evidence based category III

no experimental as comparative studies, or extrapolating recommendations
correlation studies, case-control. Class I or II evidence
clinical reviews.

IV. Evidence of expert committee, D. Direct evidence based category IV

reports, opinions or clinical experience or extrapolating recommendations
of authorities in the field or both Evidence Class I or II

* The category of evidence indicates the user the origin of the issued recommendations. Modified Shekelle P, Woolf S, Eccles M,
Grimshaw J. Clinical guidelines. Developing guidelines. BMJ 1999; 318: 593-596.

62 Rev Med IMSS 2005; 43 (1): 61-68

They Zaron the characteristics described in Table I. classi-
fication of
Annotations to the algorithm
1. The family physician clinically corroborates the diagnosis
of cervical sprain and classified into grades according
to the classification of Quebec Task Force It is shown in
Table II. Aggregates are considered symptoms:
dizziness, ver- tigo, headache, tinnitus, deafness,
phosphenes, dis- fagia, pain in jaw, shoulder or back
and emotional instability, a situation that is pre- sents in
44% of cases with grade I in 29% grade II and grade III
16% (IIIC). 10
Radiologic studies are requested rule out bone or To
unlock degenerative lesions, since there is evidence
that the radiological changes observed in the
physiological curvature of the cervical spine
(rectification or inversion lordosis) do not always
correlate with the mechanism degree sprain injury or
because its origin puededeberse to post-tural defects
(IIID, Ia a). 3,17
2. Grade III sprains or to other cervical pathology
braquialgia, systematization or complication, must
refer the patient to the emergency department of
traumatology.
3. The family physician initiates pharmacological and
non-pharmacological treatment in patients with cervical
sprain grade I or II.
Using collar and type thereof (soft, semi-rigid or
rigid) is controversial, how- ever, there is evidence
linking early removal of the collar with a lower cia
incidental complications or persistent pain, so it is
recommended is removed at seven to 10 days of
injury, assessing the neutral state rológico and
ensuring that the patient performed the treatment
set to avoid residual pain. *
4. Drug treatment: one of the follow- if- schemes 5 to
7 days:
Naproxen 250 mg tablets, two within 12 hours, more
paracetamol 500mg tablets, one or two every 8
hours.
Piroxicam 20 mg tablets, once every 24 hours, more
paracetamol 500mg tablets, one or two every eight
hours.
Rev Med IMSS 2005; 43 (1): 61-68
Diclofenac tablets 100 mg, once every 24 hours, Susana Gonzalez
more paracetamol 500mg tablets, one or two every Ramirez et al. guide
rehabilitation clinic
eight hours.
Whiplash
Add ranitidine 150 mg tablets, one every 12
hours, if acid peptic disease.
5. Non-drug treatment: Apply cryotherapy in the first
48 hours after injury (IIID). 3
After 48 hours of injury, start the application of
surface heat with water bag, or infrared heating
pad on the affected area for 20 minutes or more
to obtain the benefits of apy termote-:
vasodilation, muscle relaxation, dis - comminution * Criterion formulated by
pain (IIIC, Ia A, IIIC). 10,14,18 consensus by the manufacturer
of the guide team
Indicate relative rest. Indicate normal diet without
irritants. Communication with the service
Rehabilitation of primary care, to give the patient
a teaching session or group information, given by
the nurse service, on measures of postural
hygiene column (Annex 1) (Ia A, Ia B). 14,15
Teach patients the following therapeutic exercises
to be performed three times a day, 10 times each,
slowly:
- Neck: actively mobilize the head flexion, lateral
extension (ear closer to the shoulder) and rotation
(move the head to the right and to the left).
table II
Quebec Task Force classification
Grade symptomology
0 asymptomatic I
cervical pain, contracture, no physical signs II
Stiffness, pain located
III Symptoms, signs and neurological symptoms
IV Bone injury fracture / dislocation
Source: References 10, 14 and 16
63
 Susana - Shoulders and upper extremities: raise
Gonzalez Ramirez shoulders, flexion, extension, abduction and
et al. adduction of the upper extremities (IIIC, Ia C, IV). 2,4,8
guide rehabilitation
clinic Whiplash
6. If possible risk of work, the patient refer- RIR Health
Service under traf- for qualification. The granting
of temporary incapacity for work and its duration
will depend on the clinical picture and labor
activity performed by the patient (Table III).
8. In the event of improvement, consider with indications
of high medical home exercise and postural hygiene
measures column.
9. Refer to the patient to the emergency services trauma
in the presence of systematisation (Table IV),
severe pain or bone lesions previously undetected.
10. Refer the patient to the rehabilitation of the first
level if the move- ment limiting muscle spasm or
not to give the basic treatment, or if further has a
preexisting pathology (osteoarthrosis).

7. subsequent evaluation carried out on the seventh
* Criteria formulated by
day of the injury to determine Me- Joria or
consensus by the
remission of symptoms, valo- rar removal of the
construction team guide
collar or stay for another week, and identify
probable neurological or vascular complications.
11. The rehabilitation doctor confirms diagnosis of
cervical sprain, classifies the degree of injury and
defines rehabilitative treatment, including: Briefing
on postural hygiene column with load handling
Relaxation (Annex 1). Assesses whether drug
treatment is continued. It provides temporary
inability to low according to clinical and patient
physical activity at work (Table III) TRA. Establishes
and oversees rehabilitation treatment.

table III
Time disability in relation to labor activity of the patient (IIIC) 9 12. Options supervised treatment: * interferential
currents at the site of the lesion with analgesic
Type of work Minimum Optimum Maximum and anti-edema mode for 15 to 20 minutes,
compresahúmedo-surface heat with hot or
Sedentary 1 1 7
infrared rays for 20 minutes, and neck exercises
Light 1 3 7
and shoulder girdle .
Moderate 3 7 14
Heavy 3 twenty-one 28
Very heavy 3 28 42

table IV
Evaluation of neurologic injury to the cervical spine (Ia B, IV, III) 5,19,20

Neurological injury level C-5: deltoid weakness, decreased or absent biceps reflex and decreased sensitivity
external face of shoulder and arm.
Neurological injury level C-6: weak wrist extensors and decreased sensitivity forearm, thumb and middle finger.

Neurological injury level C-7: flexor weakness wrist, and hypoesthesia diminished reflex triceps middle finger.

Neurological injury level C-8: weakness of the finger flexors, altered sensitivity of the distal half of the forearm,
ring and little fingers.

Root affected muscles Reflection Sensitivity

C-5 Deltoid Bicipital lateral surface of the arm

C-6 Wrist extensor brachioradialis outer surface of the forearm,
and brachioradialis thumb, index and middle finger half.
C-7 Wrist flexor triceps outer side of the middle finger.
C-8 Flexor digitorum Any Forearm inner region

64 Rev Med IMSS 2005; 43 (1): 61-68

 Ultrasound at doses of 0.5 to 1 w / cm 2 for 7
minutes, surface heat with hot damp pad or
infrared rays for 20 minutes, and neck exercises
and shoulder girdle. Ultrasound at doses of 0.5 to
1 w / cm 2 for 7 minutes, galvanic currents in
affected area, and neck exercises and shoulder
girdle. Tens to 80 Hz for 15 minutes, heat super-
ficial wet-hot compress or infrared rays for 20
minutes, and neck exercises and shoulder girdle.
interferential currents with anal- Gesica mode for
15 minutes with húmdo-surface heat or hot
compress infra- rrojos rays for 20 minutes, cervical
traction preferably supine or sitting position, with
neck flexion of 20 to 30 degrees for 10 minutes,
starting with 3 kg weight and increase half kilo per
day up to 10% of patient body weight; exercises
for the neck and shoulder girdle. (Appendix 2).
This alternative is recommended as first choice in
cases of pre-existing pathology (osteoar- trosis) or
with previous strains.
13. Reassessment by the rehabilitator doctor who evaluated
clinically cervical mobility, shoulder girdle and shoulders,
muscle strength and neurological status. If you determine
improvement or remission of symptoms, develops and
performs high service liaison with the family doctor.
14. The medical rehabilitation refer the patient to the
emergency services trauma in the presence of
neurologic compromise (Table IV), severe pain or
bone lesions previously undetected.
15. Home Program: includes exercises and muscle
reeducation column hygienic measures (Annexes 1
and 3).
References
1. E. Apsit muscle reeducation of cervicalgias. Medical-Surgical
Encyclopedia. Paris, France: Elsevier; 2003; 26 (294): 1-19.
2. Badelon BF, Bebión And Haffray H, Badelon I. rehabilita- tion of
injuries of the cervical spine in the absence of neurological
lesions. Medical-Surgical Encyclopedia. Paris, France: Elsevier;
2003; 26 (285): 1-15.
3. Bertholus P, Brault JF, Legrand C, Burlot PM, Verhaeghe M,
Charpentier P. temporary devices. Medical-Surgical
Encyclopedia. Paris, France: Elsevier; 2003; 26 (160): 1-25.
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4. National Institute of Arthritis and Musculoskeletal and Skin Diseases Susana Gonzalez
(NIAMS). Preventing chronic whiplash pain. Ramirez et al. guide
www.clinicaltrials.gov/ct/gui/show/NCT00021476 rehabilitation clinic
5. Evidence-Based Panel Philadelphia Clinical Practice. Guidelines on Whiplash
selected rehabilitation interventions for neck pain. Phys Ther 2001;
81 (10): 1701-1717.
6. Borchgrevink GE, Kaasa A, McDonah D, Stikes TC, Haraldseth O,
Lereim L. Acute treatment of whiplash injuries neck sprain. A
randomized trial of treatment During the first 14 days after a car
accident. Spine 1998; 23 (1): 25-31.
7. Stanford B. Givens Injuries the cold treatment. The Physician and
Sports Medicine. 1996 March; 24 (3): 1-4.
www.physsportsmed.com/issues/1996/03_96/ cold.htm
09/07/2002.
8. Karjalainen K, Malmivaara A, Van Tulder M, Roine R, Jauhiainen M,
Hurri H, Koe B. Multidisciplinary biopsy- chosocial rehabilitation for
neck and shoulder pain working age adults Among. The Cochrane
Database Systematic Review; 2002.
9. Bruce C. Soft tissue injuries and back pain spine. Rosen P,
Barkin R, editors. Emergency Medicine. 4 th
edition. St. Louis: Mosby; 1998. p. 878-905.
10. Warren J, Bilkey Jr. Manual medicine approach to the cervical
spine and whiplash injury. Phys Med Rehabil Clin N Am 1996;
(4): 749-759.
11. Cibeira JB. Cervicobraquialgias. Microtrauma disease.
Buenos Aires, Argentina: Pan American;
2001. p. 165-210.
12. Coordination Health at Work. Health statistics memory
at work. Mexico: Directorate of Medical Services, IMSS;
2000.
13. Mishra A. Neck sprain or strain (sometimes Known as Whiplash).
In: www.emedx.com/emedx/diagnosis _ information /
back-neck_disorders / neck_sprain_ outline.htm
14. Gross AR, Aker PD, CH Goldsmith, P. Physical medicine Peloso
Modalities for mechanical neck disorders. The Cochrane Database
Systematic Review; 2002.
15. Peloso P, Gross AR, Aker P, Goldsmith CH. Drug therapy for
mechanical neck disorders. The Cochrane Database Systematic
Review; 2002.
16. Verhagen A, Peeters GG, Bie RA, Oostendorp RA.
Conservative treatment for whiplash. The Cochrane
Database Systematic Review; 2002.
17. Gross AR, Aker PD, Goldsmith CH, Peloso P. Patient education
for mechanical neck disorders. The Cochrane Database
Systematic Review; 2002.
18. Lovell ME, Galasko CSB. Whiplash disorders-review. Int J Care Injury
2002; 33; 97-101.
19. Rene C. Pain Syndromes neck and arms. Mexico: El Manual
Moderno; 1991. p. 153-164.
20. Hoppenfeld S. Neurology Orthopedic Mexico: El Manual
Moderno 1981. p. 5-27.
21. Doctor Back. ? Sprained cervical.www.google.com.mx/ search q =
cache: AXbR_5QH1AEJ: cuidelaespalda.com/
FORMACION_CONTINUADA / ESGUINCE_ continued
CERVICAL.html + training + + + cervical sprain & hl = en
65
Algorithm. Diagnosis, classification and treatment Whiplash

66 Rev Med IMSS 2005; 43 (1): 61-68

 Appendix 1 Susana Gonzalez
Ramirez et al. guide
column hygienic measures (IIIC IIIC, Ia A, B Ia, Ia A, IV) 9,10,14,15,17,21
rehabilitation clinic
Whiplash

Column hygienic measures are recommendations that are intended to prevent injury, maintain function and delay the
degenerative process.

postural

Lying above: It should be placed a small pillow cover head without shoulders, and a small pillow under your knees to
maintain a flexion of 15 degrees.
Lying On Side: place a large pillow between your neck and shoulder and a pillow between your knees.

Laying face down: place a pillow under the waist and ankles a little low; rotate the head side desired.

Seated: using preferably a straight back chair with hip flexion 90 degrees and 90 degrees knees.

Standing: semiflexionar recommended knee (rest position soldier) or leaning on a stool of about 20 centimeters
high. Also, you must toggle the semiflexion knee with both legs.

Adopt positions to activities of daily life and work.

Load handling

When picking up objects from the floor, weighing or not, you should crouch with knees bent and load the object close
to the body.
Loading an object, the weight should be exchanged in each arm. Loading two objects must perform symmetrically to level
the load. To load heavy objects it should help with shopping, hooks and hoists. To push or pull objects should be placed
one leg forward, flexing the knee to perform the movement.

Relaxation

Lying for 20 or 30 minutes, placing a pillow under the waist and another small low ankles. Rotate the head side
desired. Lying above without a pillow in the head and with two or three pillows under the knees, for 20 or 30 minutes.

Lying above, with a small pillow to head level without embracing shoulders, and another small pillow under your knees to
maintain a flexion of 15 degrees. Inhale air through the nose hold three seconds and exhale through the mouth.

By performing these relaxation techniques to concentrate and think about nice things.

Rev Med IMSS 2005; 43 (1): 61-68 67

 Susana Annex 2
Gonzalez Ramirez
Cervical traction
et al.
guide rehabilitation
clinic Whiplash

Annex 3
Muscle rehabilitation exercises

68 Rev Med IMSS 2005; 43 (1): 61-68