PROGNOSIS OF WHIPLASH-ASSOCIATED DISORDERS: SUMMARY OF EVIDENCE AND RECOMMENDATIONS

INITIAL FINDINGS EVIDENCERECOMMENDATIONS FOR CLINICAL PRACTICERESEARCH RECOMMENDATIONS
Symptoms - Three accepted studies provide information on symptoms that are useful for predicting recovery. These studies, however, did not cover similar symptoms and outcome measures.

- Similarly, only one accepted study provided useful information about signs of prognostic value.

- Therefore, our recommendations are based on both evidence and the Task Force consensus.

- Data on symptoms and signs present at time of first visit should be recorded. These should include all symptoms and signs that are needed to classify patients into Grade I to III (see table on diagnosis for a list of symptoms and signs).

- These signs and symptoms should be recorded on a standard form (see form in Appendix I).

- There is a need for adequate studies of the prognostic value of symptoms, signs, radiological findings, psychological factors, and sociodemographic predictors in WAD patients. These studies should be based on exhaustive cohorts of patients, similar definitions of zero time, predictors, outcome, and follow-up procedures. These studies should have a sample size sufficient to do subgroup analysis and modelling of interactions. These prognostic studies should examine both short and long term outcome of WAD.
Radiological findings - Although several accepted studies addressed radiological findings, none of the results are definitive.

- Our recommendations therefore, are based on both evidence and the Task Force consensus.

- Data on radiological findings such as osteophytes and narrowing of the disc space should be recorded during the first visit.
Sociodemographic factors - Of the 11 studies accepted, 2 provided data on potential predictive factors.

- Our recommendation is therefore based on both evidence and the Task Force consensus.

- History taking should include basic socio-demographic information such as age, gender, number of dependent, marital status. - Prognostic studies should result in the development of pain rating or disability rating tools specific to WAD. Validity and reliability of these tools should be assessed in adequate studies.

PROGNOSIS OF WHIPLASH-ASSOCIATED DISORDERS: SUMMARY OF EVIDENCE AND RECOMMENDATIONS

TREATMENTEVIDENCERECOMMENDATIONS FOR CLINICAL PRACTICERESEARCH RECOMMENDATIONS
IMMOBILIZATIONEvidenceEvidence-based Consensus-BasedResearch recommendations
Collars- No research was found addressing independent benefit of collars in WAD.

- Soft collars in combination with prescribed rest and analgesics are associated with delayed recovery (Pain and ROM) in WAD presenting within 4 days of injury.

- Soft collars do not restrict ROM in non-injured subjects

There is weak cumulative evidence to restrict their use to short periods of time.Collars should not be prescribed for Grade I WAD. If prescribed for Grade II or III, they should be restricted to no more than 72 hrs.RCTs are needed to assess the short-term benefits (efficacy + effectiveness) of cervical collars in WAD.
Prescribed Rest- No research was found concerning independent benefit of prescribed rest in WAD.

- Prescribed rest for 10-14 days in combination with soft collars and analgesia in WAD was associated with delayed recovery.

There is weak cumulative evidence to restrict prescribed rest to short periods of time.Rest should not be prescribed for WAD I.

Rest > 4 days should not

be prescribed for WAD II

and III.

RCTs are needed to assess the short- and long-term benefits (efficacy and effectiveness) of prescribed rest in WAD.
Cervical Pillows- No research was found addressing the therapeutic effects of cervical pillows in WAD.Cervical pillows are not required.No research is recommended.
ACTIVATION

Manipulation

- No research was found addressing the short-term or long term benefits of a complete course of manipulative therapy on WAD.

- The immediate effect on pain and ROM of a single manipulation is similar to that of a single mobilization in neck pain of varying durations. There is insufficient evidence assessing the independent contribution of this technique.

A short-term regimen of manipulation can be used for WAD. This technique should be restricted to qualified personnel. RCTs are essential to assess the short-term and long-term benefits of a regimen of manipulative therapy in WAD.
EvidenceEvidence-BasedConsensus-BasedResearch Recommendations
Mobilization- No research was found concerning the independent effect of mobilization on WAD.

- Manual mobilization combined with other physiotherapeutic interventions in WAD presenting within 4 days of injury and in neck pain syndromes of indeterminate duration, was shown to have short-term benefit; long-term results are no better than those for combined collar, rest, and analgesics.

There is weak cumulative evidence to support their combined use in WAD.A regimen of mobilization can be used for WAD.RCTs are essential to assess the short-term and long-term benefits of a regimen of mobilization therapy in WAD.
Exercise- No research was found regarding independent benefit of exercise in WAD.

- Prescription of home exercise combined with activation advice, was found to have short- and long-term benefit for WAD presenting within 4 days of injury.

There is insufficient evidence assessing the independent contribution of exercise.ROM exercises should be implemented immediately, in combination if necessary with intermittent rest when pain is severe. Clinical judgement is crucial if symptoms are aggravated.RCTs are needed to assess the short-term and long-term benefits of exercise in WAD.
Postural Advice- No research was found concerning the independent therapeutic effect of postural alignment in WAD.

- Advice on posture, combined with advice on activation for WAD presenting within 4 days of injury, has short-and long-term benefit; combined with physio-therapy soft collar and analgesics there was only short-term benefit.

Postural advice can be given in combination with activation in WAD.RCTs are needed to assess the short-term and long-term benefits of postural advice in WAD.
Spray & Stretch- No research was found concerning the independent therapeutic effect of spray and stretch in WAD. Spray and stretch is not recommended. The benefit of spray and stretch for any grade and duration of WAD should be established in RCTs.
Traction- No research was found addressing independent effects of traction in WAD.

- Traction in combination with other physiotherapeutic interventions was found to be of short-term benefit in WAD presenting within 4 days of injury, and in neck pain syndromes of indeterminate duration; there was no long-term (2-year) benefit for WAD presenting within 4 days of injury.

In a small RCT, there were no statistically significant differences between static, intermittent, and manual traction in combination with other physiotherapeutic interventions in neck pain syndromes of indeterminate duration.

There is weak evidence that traction is of short-term benefit. A regimen of traction can be used in combination with other mobilizing interventions in WAD.RCTs are required to assess the independent and combined benefits of traction in WAD.
PASSIVE MODALITIES/ ELECTRO-THERAPIESEvidenceEvidence-basedConsensus-basedResearch recommendations
Heat, ice, massage, TENS, PEMT, electrical stimulation, ultrasound, laser, short-wave diatheryThere were virtually no accepted studies addressing the benefit of these modalities.

- Two small RCTs in WAD I + II presenting < 72 hours; and in neck pain not related to WAD, > 8 weeks duration, suggest a benefit from PEMT compared to sham PEMT in pain control when combined with NSAIDs, activating advice and soft collar.

- All modalities except laser were possible adjuncts to mobilizing interventions, which had short term benefit equivalent to activation advice.

- There were no accepted studies in which the benefit of laser was addressed.

Grade I: Although active PEMT in a soft collar was better than sham PEMT in a soft collar, PEMT is not recommended, because it involves wearing a soft collar 8 hours/day for 12 weeks.

Grade II and III: The other professionally administered passive modalities/ electrotherapies are optional adjuncts during the first 3 weeks to activating interventions with emphasis on return as soon as possible to usual activity.

- Direct immediate resarch efforts to Grade II < 3 weeks. Evaluate efficacy/ effectiveness of passive modalities in symptom (pain) relief and improvement of function. Research should evaluate their independent effects, and additive effects of combined interventions.

- If efficacy shown for Grade II, proceed to evaluate effectiveness and cost-effectiveness for Grade III < 3 weeks

- If efficacy shown for Grade II or III < 3 weeks, may proceed to evaluate the above beyond 3 weeks.

SURGICAL TREATMENT - No studies were accepted concerning the benefit of disc surgery, nerve block, or rhizolysis for any grade or duration in WAD.

- One accepted small RCT suggests no effect of intraarticular steroid injection (facet block) for WAD neck pain > 3 months duration.

There are no indications for surgical intervention in WAD Grades I and II. Surgery is to be restricted to the rare WAD Grade III with persistent arm pain that does not respond to conservative management, or with rapidly progressing neurologic deficit. An RCT for efficacy of surgery for nerve root entrapment secondary to WAD Grade III is desirable. Considering the low occurrence of the clinical indications for surgery in WAD Grade III, a multicenter RCT is desirable.

INJECTIONSEvidenceEvidence-basedConsensus-basedResearch recommendations
Steroid InjectionsOne accepted study showed no benefit of intra-articular steroid injection in WAD , 3 mo.

No accepted studies were found concerning the benefit of epidural or intrathecal steroid injections in WAD. No research was found concerning trigger point steroid injections in WAD.

Intrarticular steroid injection can not be recommended for WAD.

Epidural steroid injections should not be used for Grade I or II WAD. Occasionally, Grade III WAD with unresolved radicular pain of > 1 month might benefit from epidural steroid injections.

There is no indication for

steroid trigger point injection in the "acute" phase (< 3 weeks). Because harmful side effects of repeated steroid use have been reported, steroid trigger point injections should not be used unless their benefit in WAD is demonstrated in valid RCTs.

Intrathecal steroid injections carry such risk of serious morbidity that they should be avoided in all Grades of WAD.

Sterile water injectionsOne accepted RCT on WAD Grade II patients with neck and shoulder pain 4-6 years after injury suggested a sustained small benefit of subcutaneous sterile water injection.Sterile water subcutaneous trigger point injections can be used for WAD II where trigger points are present as an optional adjunct to activating interventions with emphasis on return to usual activities.RCT's are needed to confirm the efficacy and effectiveness of sterile water injections.
PHARMACOLOGYNo research was found regarding the benefit of narcotic analgesics or psychopharmacologics in WAD. No studies were accepted regarding the benefit of muscle relaxants in WAD.

Analgesics or NSAIDs in combination with other treatment modalities were found to be of short-term benefit in WAD I and II presenting within 3 days of injury (see activation, passive modalities).

No medications should be prescribed for WAD Grade I. Non-narcotic analgesics & NSAIDs can be used to alleviate pain for the short-term in WAD II and III. Their use should not be continued for more than three weeks, and should be weighed against possible side effects.

Narcotic analgesics should not be prescribed for Grade I & II WAD. Occasionally they may be prescribed for pain relief in acute severe Grade III, but only for a limited period of time. Although commonly prescribed, muscle relaxants should not generally be used in the acute phase of WAD.

The psychopharmacologic drugs are not recommended for use on a general basis in WAD of any duration or Grade, but they may be used occasionally, for symptoms such as insomnia or tension, as an adjunct to activating interventions in the acute phase (< 3 months duration).

For chronic pain in WAD (> 3 months duration), the minor tranquilizers and anti-depressents may be used.

RCT's are needed to assess the efficacy and effectiveness of pharmacologic interventions in WAD.
MISCELLANEOUS INTERVENTIONS
(formally prescribed)
EvidenceEvidence-basedConsensus-basedResearch recommendations
Prescribed function, neck school, work alteration and relaxation techniques, acupuncture.One accepted RCT was found for chronic neck pain (daily neck pain with or without radiation $ 6 months). The study suggested that acupuncture and NSAIDs or analgesics were no better than sham TENS with NSAIDs or analgesics for relief of pain.

No research was found concerning the other treatments.

Grade I : Prescribed function, i.e. immediate return to usual activity, is recommended. Neck school, work alteration and relaxation techniques are not indicated for Grade I.

Grade II and III: Prescribed function, i.e. return to usual activity, is encouraged as soon as possible.

Neck school, temporary work alteration, relaxation techniques and acupuncture are optional adjuncts for symptom duration > 3 weeks.

- First, direct research efforts to Grade II and III. The studies should evaluate duration of symptoms, function and recurrence.

- Evaluate efficacy of acupuncture in WAD Grade II and III $ 3 weeks.

- Evaluate efficacy of work alteration in WAD Grade II and III $ 3 weeks.

- Evaluate efficacy of neck school in WAD Grade II and III $ 3 weeks.

OTHER INTERVENTIONS (not formally prescribed)

Magnetic Necklace, relaxation techniques, topicals, herbals and homeopathic remedies, over the counter medication, reflexology and others.

An accepted RCT indicated that the magnetic necklace is no better than placebo for neck pain of duration greater than one year. No other reasearch was found concerning the effectiveness of the magnetic necklace.

No research was found concerning any of the other interventions.

There is no reason for a practitioner to prescribe any of these treatments. Further, the practitioner should recommend against the magnetic necklace.

PROGNOSIS OF WHIPLASH-ASSOCIATED DISORDERS: SUMMARY OF EVIDENCE AND RECOMMENDATIONS

DIAGNOSISEVIDENCERECOMMENDATIONS FOR CLINICAL PRACTICERESEARCH RECOMMENDATIONS
History takingTwenty studies dealing with aspects of the patient history in diagnosis of WAD were reviewed. No accepted study dealt with the value of history taking for the positive diagnosis of WAD.

These recommendations are based on the consensus of the Task Force.

- History taking is important during all visits for the management of WAD patients of all grades.

- The history should include information about:

- date of birth, gender, occupation, number of dependents, marital status;

- prior history of neck problems, including previous whiplash;

- symptoms including: pain, stiffness, numbness, weakness and associated extra-cervical symptoms;

- localization, time of onset, and profile of onset should be recorded for all symptoms;

- circumstances of injury (sport, motor vehicle...);

- mechanism of injury.

- This minimal history should be recorded on a standard form (see Appendix I).

Studies assessing the validity and reliability of the patient history for the positive diagnosis of WAD are needed.

- The impact of the minimal data collection form should be evaluated.

Physical examinationEighteen studies dealing with aspects of physical examination of WAD patients were reviewed. No accepted study dealt with the value of physical examination for the positive diagnosis of WAD.

These recommendations are based on the consensus of the Task Force.

- A focussed physical examination is necessary during all patient visits.

- The physical examination should include at least:

- inspection;

- palpation for tender points;

- assessment of range of motion in flexion/ extension, rotation, and lateral flexion;

- neurological exam to assess sensorimotor function and tendon reflexes of upper and lower limbs;

- assessment of associated injuries;

- assessment of general medical condition, as needed.

- Results of the minimal physical examination should be recorded on a standard form (see Appendix I).

- Studies assessing the validity and reliability of physical examination in the diagnosis of WAD are needed.

- The impact of the minimal data collection form should be evaluated.

Plain X rays- Sixty-one studies dealing with plain X rays in WAD patients were reviewed. No accepted study dealt with the value of plain X rays for the positive diagnosis of WAD.

- Plain X rays are not useful for the diagnosis of WAD I, II and III. X rays are needed, however, to diagnose bony lesions of WAD IV. There is a suggestion in the literature that WAD patients with Grade I WAD and no other injury, with no mid-line cervical pain, with normal alertness and attention, and who are not obtunded by narcotics, alcohol, or other drugs, may not need X rays. The small sample size of these studies, and the resulting uncertainty around estimates of false negative and positive rates made it impossible to make recommendations about plain X rays on the basis of scientific data.

- Therefore, the recommendations regarding plain X rays in diagnosis of WAD are based on the consensus of the Task Force.

- All patients in Grade II and III who present with WAD should have baseline radiologic examination of the cervical spine. This examination should include anteroposterior, lateral and open mouth views.

- All seven cervical vertebral and the C7-T1 disc space should be well visualized.

- In patients with Grade II or III WAD, flexion/ extension views may occasionally be indicated.

- Grade I patients who are conscious, show no evidence of alcohol-related impairment, are not obtunded by narcotics or other drugs, and who show no physical signs on examination require no plain X rays upon presentation.

- Studies to determine optimal use of plain X rays in patients with minimal symptomatology after a whiplash are needed. These studies should compare history, physical examination, plain X rays, and comprehensive assessment of the cervical spine, in a cohort of sufficient size and composition to estimate sensitivity, specificity, and predictive values with precision.

- Studies of plain X rays in WAD should include assessments of cost, benefits and cost-effectiveness, including adverse side-effects of X ray exposure.

Specialized imaging technique- One study dealing with tomograms, 10 studies of CT scan, 5 of MRI, 1 study of myelography, 1 study of discography, 3 studies of scintigraphy, and no studies of angiography were reviewed.

- No accepted studies dealt with CT scans in WAD patients; one study dealt with MRI, but did not provide any evidence that this technique might be useful for the diagnosis of WAD.

- Specialized imaging techniques are not useful for the positive diagnosis of WAD I to III.

- Specialized imaging techniques might be necessary, in some instances, to make the positive diagnosis of Grade IV.

- Therefore, these recommendations are based on Task Force consensus.

- There is no role for special imaging techniques (tomography, CT scan, MRI, myelography, discography, scintigraphy, angiography, ...) in Grade I and II WAD patients;

- Special imaging techniques might be used in selected Grade III patients based on the advice of an accredited medical or surgical specialist.

- Studies of the validity and reliability of special imaging techniques for the diagnosis of WAD patients are needed.

- Studies of cost benefits and cost effectiveness of special imaging techniques in patients with WAD are needed.

- Research on specialized imaging techniques should prioritize evaluation of MRI to assess soft tissues.

Special examsWe examined 1 study dealing with evoked potentials (SSEP). No accepted study dealt with evoked potential in WAD.

We examined 4 studies of selective nerve root blocks and 2 studies of EMG. There were no accepted studies of these exams in WAD patients.

We examined 5 studies of neurobehavioral tests, 6 studies of EEG, 1 study of ENG, 2 studies of other special audiology or visual exams. There were no accepted studies of any of these special exams in patients with WAD.

- Therefore, all recommendations regarding these special exams are based on the consensus of the Task Force.

- Indications for evoked potentials (SSEP) in Grade III patients should be based on the advice of an accreditated medical or surgical specialist.

- Indications for selective nerve root blocks and of EMG in Grade II and III WAD patients should be based on the advice of an accredited medical or surgical specialist.

- Indications for all other special exams in WAD patients should be based on the advice of an accredited medical or surgical specialist.

- There is a need for adequate studies of validity, reliability, cost benefit and cost effectiveness of special exams for the diagnosis of associated lesions in WAD patients.

- However, because of the small numbers of patients with indications for such specialized exam, it is foreseen that these studies actually, might be difficult to implement.