MAJOR FINDINGS AND RECOMMENDATIONS
The systematic review of the original research literature yielded little scientifically rigorous information addressing the mandate to the Task Force by the Société d'assurance automobile du Québec (SAAQ). The consensus recommendations that follow are based on the best available evidence, or where evidence was lacking, on the combined experience and judgement emerging after extended in-depth discussions of the Task Force members. Consultation with external experts, information from a study initiated during the deliberations and inference from relevant literature that does not address WAD specifically were also invoked. We have also put forward some controversial courses of action in the belief that public debate would be of value. Although commissioned in Quebec for Quebeckers, we believe that the conclusions and recommendations are appropriate to other populations.
THE SOCIAL IMPACT OF WHIPLASH-ASSOCIATED DISORDERS
THE INCIDENCE OF WHIPLASH-ASSOCIATED DISORDERS IS HIGHLY VARIABLE. The one-year incidence rate of compensated claims for Whiplash-Associated Disorders (WAD) in Quebec in 1987 was 70 per 100 000 inhabitants. Incidence rates in other provinces of Canada differ considerably from this. The marked variation in WAD claims from province to province raises the possibility that system differences, such as no fault insurance in Quebec and the tort system in Saskatchewan, may affect the frequency of claims and chronicity of cases.
WHIPLASH-ASSOCIATED DISORDERS ARE USUALLY SELF-LIMITED. In a cohort of persons compensated for whiplash injuries occurring in 1987 in Quebec, the median time to recovery (end of disability compensation) was 31 days. Fifty-five percent of the cohort filed claims for whiplash only; 1.9% of these were still disabled one year after their injury.
CASES LASTING MORE THAN SIX MONTHS AND CASES OF TWO TO SIX MONTHS DURATION ARE RESPONSIBLE FOR MOST OF THE DISABILITY COSTS FROM WHIPLASH-ASSOCIATED DISORDERS. Of persons with compensated claims for whiplash injuries in a cohort followed for five years in Quebec, 12% received disability compensation for more than six months following the collision episode. These 12% of patients accounted for 46% of the costs paid by the SAAQ. Another 38% of costs paid by the SAAQ are associated with disabilities of two to six months duration. This finding is analogous to findings of the economic costs of other musculoskeletal disorders, notably low back pain in the workplace.
DIAGNOSTIC CRITERIA AND NOMENCLATURE USED IN WHIPLASH-ASSOCIATED DISORDERS ARE CONFUSING AND ARE NOT STANDARDIZED. THIS IS A MAJOR BARRIER TO A BETTER UNDERSTANDING OF WHIPLASH-ASSOCIATED DISORDERS. Inconsistent definitions, descriptions and classifications used in reports of WAD and in common clinical use make it impossible to compare and synthesize the findings of published studies. A lack of systematic stratification of severity similarly limits the usefulness of both administrative data and research reports.
THE PREVENTION OF CHRONIC WHIPLASH-ASSOCIATED DISORDERS IS AN IMPORTANT CHALLENGE FOR SOCIETY AND THE HEALTH CARE SYSTEM. A major challenge for the health care system, the insurance industry, health professions and the public is to prevent chronic disability related to WAD and to provide effective care to reduce chronicity. Risk factors for chronicity have had little study.
ALL REPORTS OF WHIPLASH-ASSOCIATED DISORDERS SHOULD CONFORM TO A STANDARDIZED CLASSIFICATION SCHEME. Building on previous work of others, we propose the Quebec Classification of Whiplash-Associated Disorders (see Section 3: Consensus Findings). This clinical classification scheme describes mutually exclusive and collectively exhaustive categories of WAD, which should facilitate research and administrative reporting. Its reliability, comprehensiveness and prognostic utility should be tested formally.
ALL NEW INCIDENTS OF WHIPLASH-ASSOCIATED DISORDERS SHOULD BE REPORTED ON A STANDARDIZED FORM. All persons involved in an acceleration-deceleration collision with possible WAD who are seeking care for the first time or initiating an insurance claim should complete a standardized form that provides basic personal, sociodemographic, clinical, vehicular environmental data and information on the dynamics of the collision (See Appendix I). This requirement will enhance the quality of follow-up evaluations, permit epidemiological surveillance of the population and foster the pursuit of the research priorities set forth in this Scientific Monograph. Health professionals not reporting standardized data should not be reimbursed and patients who do not provide information should be ineligible for benefits from SAAQ.
PATIENTS SHOULD BE REASSURED THAT WHIPLASH-ASSOCIATED DISORDERS ARE ALMOST ALWAYS SELF-LIMITED. Health professionals caring for patients with WAD should emphasize that most incidents of WAD are self-limited, involving temporary discomfort and rarely resulting in permanent harm. All interventions, particularly at inception of the episode, should be accompanied by reassurance about the favorable prognosis and the need to resume usual activities as soon as possible. The key message to the WAD patient is that pain is not harmful, is usually short-lived and is controllable.
THE EFFECT OF DIFFERENT SOCIAL AND INSURANCE POLICIES SUCH AS NO FAULT INSURANCE ON INCIDENCE AND CHRONICITY OF WHIPLASH-ASSOCIATED DISORDERS SHOULD BE STUDIED. The possibility that the marked variation in WAD claims from province to province may in part be attributed to insurance system differences such as no-fault insurance should be investigated by means of formal evaluative studies incorporating health economics.
PREVENTION OF WHIPLASH-ASSOCIATED DISORDERS
THE EFFECTIVENESS OF SEAT BELTS IN PREVENTING NECK INJURY HAS NOT BEEN CLARIFIED. There are suggestions from the literature that seat belts may increase the incidence of neck injuries (WAD I, II and III in our classification), especially when not worn properly. This increase is minor and is largely offset by the demonstrated effectiveness of seat belts in decreasing overall fatality and the incidence of severe head, face and other injuries. There are no studies of the effect of air bags and other automatic protection devices on the frequency and severity of WAD. Controversy exists about whether the use of seat belts affects the recovery of WAD patients.
PROPERLY FITTED HEADRESTS REDUCE SEVERITY OF WHIPLASH-ASSOCIATED DISORDERS. In rear-end collisions, there is evidence that a headrest, which is in line with the seat, positioned close to the individual at the level of the occiput, made of the same material as the seat and strong enough to resist impact, but yielding enough to avoid rebound of the occupant, will reduce the incidence and severity of neck injuries.
PROMOTING GENERAL ROAD SAFETY MEASURES TO DECREASE THE RISK OF MOTOR-VEHICLE COLLISIONS WILL BE THE MOST EFFECTIVE STRATEGY TO PREVENT WHIPLASH-ASSOCIATED DISORDERS AND THEIR SEQUELAE. There are many proven primary prevention measures for decreasing the risk and severity of motor-vehicle collisions and injuries, but their implementation, dissemination and enforcement are still incomplete. We recommend that major efforts be made to promote road safety to decrease the risk and severity of WAD. Priority should be given to measures directed at making vehicles and the road environment safer, without neglecting educational/behavioral interventions. For example, the maximum possible speed of all vehicles should be reduced, and retailers who sell alcoholic beverages to persons already intoxicated and likely to drive a vehicle should be held legally accountable.
ALL VEHICLES SHOULD BE EQUIPPED WITH ADEQUATE HEADRESTS AND RESTRAINTS. Motor vehicles should be equipped with headrests for all occupants. These must be integrated in the seat and high enough to protect individuals of all heights. The seat and headrest should be of the same material to avoid differential rebound of the head and the body. All seat belts should incorporate at least three-point shoulder/lap devices and retraction mechanisms, so that forces are transmitted evenly. Seat belt and restraint use should be required for all occupants of motor vehicles without exception.
IN THE INTEREST OF SAFETY OF BOTH THE PERSON AFFECTED BY WHIPLASH-ASSOCIATED DISORDERS AND THE PUBLIC ON THE ROADS, IT MAY BE NECESSARY FOR THE INJURED PERSON TO SUSPEND OR RESTRICT DRIVING ACTIVITIES TEMPORARILY. To operate a motor vehicle in a safe manner, a person should not be affected by conditions that prevent adequate perception of the road and its environment, or which alter judgement, decision making, or reaction time. Persons with WAD who have limited range of vision resulting from restricted cervical range of motion, or exhibit associated symptoms like equilibrium dysfunction, uncontrolled vertigo, diplopia, etc., or who are obtunded by psychotropic medications or narcotic analgesics, should be advised by their physicians to limit or discontinue the operation of a motor vehicle until the medications are discontinued and signs and symptoms resolve to a point at which the safe operation of the vehicle is again possible. It is the consensus of this Task Force that a recommendation by a physician for full disability status implies limitations of the ability to operate a motor vehicle in the absence of clear evidence to the contrary.
DIAGNOSIS OF WHIPLASH-ASSOCIATED DISORDERS
THE DIAGNOSIS OF WHIPLASH-ASSOCIATED DISORDERS CAN USUALLY BE MADE CLINICALLY. An evaluation including personal information, careful medical history and directed physical examination can be used to classify patients and to assess the extent and severity of injury. There is no evidence that specialized diagnostic testing or imaging is needed on a routine basis for presumptive Grade I WAD when a subject is not obtunded and has no physical signs. Radiographs may be used selectively to rule out structural damage.
PATIENTS WITH GRADE I WHIPLASH-ASSOCIATED DISORDERS USUALLY DO NOT REQUIRE X RAYS. PATIENTS WITH PRESUMPTIVE GRADE II AND III WHIPLASH-ASSOCIATED DISORDERS NEED A BASELINE RADIOLOGICAL EXAMINATION. The clinical evaluation of a patient with apparent Grade I WAD, who is alert and not obtunded by alcohol or drugs and has no physical signs, generally does not require an X ray. All other patients with WAD should have a radiological examination, consisting of plain films with anteroposterior, lateral and open-mouth views. All seven cervical vertebrae and the C7-T1 motion segment should be visualized. Flexion and extension views as well as tomography, computer assisted tomography and other imaging techniques are indicated when the three view plain films are equivocal.
DIAGNOSTIC TESTS AND IMAGING FOR WHIPLASH-ASSOCIATED DISORDERS SHOULD BE EVALUATED CRITICALLY. There is a need for formal evaluation of history taking, physical examination and plain X rays for the diagnosis of WAD. The marginal additional value of other tests, procedures and imaging techniques for Grade II and III WAD also need assessment. These studies should be large enough to estimate precisely the frequency of false positives and false negatives, and should include assessments of costs and benefits, including considerations of adverse side-effects such as prolonging disability.
TREATMENT OF WHIPLASH-ASSOCIATED DISORDERS
MOST THERAPEUTIC INTERVENTIONS CURRENTLY USED IN PATIENTS WITH WHIPLASH-ASSOCIATED DISORDERS HAVE NOT BEEN EVALUATED IN A SCIENTIFICALLY RIGOROUS MANNER. These unproven therapies include cervical pillows, postural alignment training, acupuncture, spray and stretch, transcutaneous electrical stimulation, ultrasound, laser, short-wave diathermy, heat, ice, massage, epidural or intrathecal injections, muscle relaxants and psychosocial interventions.
TREATMENTS EVALUATED IN A SCIENTIFICALLY RIGOROUS MANNER SHOW LITTLE OR NO EVIDENCE OF EFFICACY. There is little or no evidence of efficacy for soft cervical collars, corticosteroid injections of the zygapophysial joints, pulsed electromagnetic treatment, magnetic necklace and subcutaneous sterile water injection. Use of soft cervical collars beyond the first 72 hours probably prolongs disability in WAD.
INTERVENTIONS THAT PROMOTE ACTIVITY SUCH AS MOBILIZATION, MANIPULATION AND EXERCISES, IN COMBINATION WITH ANALGESICS OR NON-STEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDs) ARE EFFECTIVE ON A TIME-LIMITED BASIS. Based on limited evidence and reasoning by analogy, it is the Task Force consensus that the use of NSAIDs and analgesics, short-term manipulation and mobilization by trained persons and active exercises are useful in Grade II and III WAD, but prolonged use of soft collars, rest or inactivity probably prolongs disability in WAD.
EARLY RETURN TO USUAL ACTIVITIES FOR WHIPLASH-ASSOCIATED DISORDER PATIENTS SHOULD BE VIGOROUSLY ENCOURAGED BY CLINICIANS. Immediate return to usual activities is recommended for Grade I WAD; work restrictions are not indicated. For Grades II and III WAD, return to usual activity as soon as possible should be encouraged, typically in less than one week for Grade II WAD. Work alterations may be prescribed for Grades II and III WAD, but should be temporary, except for clinical circumstances justified as unusual by the attending clinician or for atypical work environments. The work alteration prescription should be reassessed within three weeks.
SOFT COLLARS IN THE MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS ARE NOT RECOMMENDED. The use of soft collars in the treatment of WAD should be discouraged. Even in Grade III WAD, soft collars should not be used since they do not adequately immobilize the spine. In the majority of cases, early return to mobility is important and the use of a collar may prolong disability.
PRESCRIPTION DRUGS HAVE A LIMITED ROLE IN THE MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS AND SHOULD BE USED SPARINGLY. No medication should be prescribed in Grade I WAD. In Grade II and III WAD, non-narcotic analgesics and NSAIDs can be used to alleviate pain for a period of less than one week. In Grade III WAD narcotic analgesics may occasionally be needed for pain relief, particularly in the acute phase. Whenever narcotics are prescribed, the patient should be cautioned about possible sedative effects and advised not to drive motor vehicles or operate heavy equipment. Psychopharmacologic drugs are not recommended for WAD per se. They may be used occasionally for symptoms such as insomnia or anxiety, as an adjunct to other interventions promoting greater activity of the patient. In chronic cases of WAD (at three months or more after inception) minor tranquilizers and antidepressants may be a necessary part of multidisciplinary treatment. Muscle relaxants should not be used in the management of WAD.
PRESCRIBED REST IS SELDOM INDICATED AND SHOULD ALWAYS BE LIMITED TO A SHORT DURATION. The prescription of bed rest is not indicated for any Grade of WAD. The prescription of rest for the neck by restricting activity in Grade I WAD is not indicated. In the few cases with Grade II and III WAD in which rest for the neck might be indicated, it should be limited to less than four days and followed by early activation. Longer periods of rest require clinical reassessment.
PRACTITIONERS OF MANIPULATIVE THERAPY SHOULD EMPHASIZE EARLY RETURN TO USUAL ACTIVITY AND THE PROMOTION OF MOBILITY. The Task Force consensus is that manipulative treatments by trained persons for the relief of pain and facilitating early mobility can be used in WAD. All such treatments should be accompanied by reassurance about the good prognosis of WAD, should discourage extended dependence on the health professional and promote resumption or continuation of usual activities and work. Long-term, repeated manipulation without multidisciplinary evaluation is not justified.
PHYSIOTHERAPY SHOULD EMPHASIZE EARLY RETURN TO USUAL ACTIVITY AND THE PROMOTION OF MOBILITY. Treatments given for relief of pain and promoting early mobility are recommended primarily on the basis of consensus. All interventions by physiotherapists in WAD patients of any grade or stage should be accompanied by reassurance about its good prognosis and should promote resumption of usual activities including work. Long-term physiotherapy without multidisciplinary evaluation is not justified.
SURGERY IN WHIPLASH-ASSOCIATED DISORDERS IS RARELY INDICATED. Surgery is only indicated in WAD Grade III with progressive neurological deficit or persisting arm pain.
WIDELY ACCEPTED, STANDARDIZED GUIDELINES FOR THE MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS ARE NOT AVAILABLE.
A PATIENT CARE GUIDELINE FOR WHIPLASH-ASSOCIATED DISORDERS IS PROPOSED. The clinical management of WAD patients should recognize that most cases unassociated with other injury, i.e., isolated WAD, are self-limiting. Thus reassurance, promotion of activity and conservative management are recommended in early treatment for all three grades. The most important principle is to prevent chronicity. Unresolved disability in Grade I WAD patients requires a specialized consultation at three weeks after inception and a mandatory, multidisciplinary consultation after six weeks. For Grade II and III WAD, specialized consultation for unresolved cases should take place at 6 weeks and mandatory multidisciplinary consultation at 12 weeks. Grade I WAD patients with persisting problems should be reassessed in seven days and Grade II and III WAD patients who have not returned to usual activity in three weeks should be reassessed. Health professionals must provide essential clinical data at baseline and patients should be required to provide personal data and information on the collision to enable good follow-up. Guidelines must always be individualized for the particular patient.
PROFESSIONAL EDUCATION RELATED TO WHIPLASH-ASSOCIATED DISORDERS
TRAINING OF PRACTITIONERS AND HEALTH SCIENCE STUDENTS IN THE MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS IS DEFICIENT. Educational opportunities for clinicians in all health science faculties, including medical students, provide insufficient preparation for the management of WAD.
HEALTH-CARE PROFESSIONALS, PARTICULARLY THOSE INVOLVED IN PRIMARY CARE AND TRAUMA CARE, SHOULD HAVE IMPROVED TRAINING IN THE MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS. Traditional teaching programs should be enriched with multidisciplinary clinical content relevant to WAD. There should be more continuing educational programs, teaching materials and aids to the education of health-care professionals in the prevention, clinical evaluation, care and rehabilitation of patients with WAD. Training programs should be targeted to clinicians in trauma and primary care. These initiatives should be implemented directly and through the faculties of health sciences in the university setting.