INTERVENTIONS (TREATMENT)

The Task Force identified a number of specific treatments for Whiplash-Associated Disorders (WAD). This section synthesizes the evidence regarding efficacy and effectiveness of these treatments, based on the results of studies judged acceptable by Task Force consensus. A table describing the accepted randomized control trials (RCT) of treatments for WAD can be found in Appendix II.

Immobilization

1. Collars: Cervical collars are often prescribed to immobilize the neck in patients with WAD. Several accepted studies have shown that the soft foam collar, the Philadelphia collar, and the Queen Anne collar have little effect on cervical range of motion (ROM) in healthy adults. 17, 24, 49

Although prescription of cervical collars is common practice in WAD, no research was found addressing their independent efficacy or effectiveness for WAD. The information that is available comes from studies where collars were part of the treatment regimen prescribed for control patients in studies evaluating other interventions. Soft collars were prescribed as part of the control treatment in three RCTs evaluating mobilization 62, 63, 64 and electrotherapies. 27, 28 In all these studies, the group receiving soft collars in combination with the other control interventions had delayed recovery in terms of pain rating (by McGill Pain Questionnaire, Visual Analog Scale, or other validated method) and ROM (by several methods) compared to that of the groups receiving the interventions the studies were conducted to evaluate.

In summary, soft collars do not restrict the range of motion of the cervical spine. Moreover, collars may promote inactivity, which can delay recovery in patients with WAD.

2. Prescription of Rest: Prescription of rest in the first few days is a common recommendation for WAD. There are accepted RCTs in which prescription of rest for 10-14 days along with soft collars and analgesia was the control treatment. This was compared to mobilization or advice for WAD presenting within 72 hours 62, 63 or in the acute phase. 64 We found no studies designed to evaluate the independent effect of rest on WAD. The cumulative evidence suggests that prolonged periods of rest are detrimental to recovery from WAD.

3. Cervical Pillows: There were no studies found regarding cervical pillows for WAD.

Activation

1. Manipulation: Nansel et al 69 addressed the duration of effect of a single manipulation (adjustment) in volunteers with and without a history of neck trauma and with cervical ROM asymmetry of greater than 10 degrees. There was an equivalent immediate reduction in ROM asymmetry in both groups. However, this effect lasted less than 48 hours. In a RCT comparing the efficacy of a single manipulation and a single mobilization, Cassidy et al 14, 15 found that, after controlling for pre-treatment differences, there were equivalent immediate (less than five minutes) improvements in pain and ROM in neck pain patients, including Grade I and II WAD. There were no other accepted studies regarding the short or long-term effectiveness or efficacy of manipulation. Since manipulation is a common treatment in WAD, its value must be established in randomized controlled trials.

2. Mobilization: There were no studies found that addressed the independent effects of mobilization. There are several accepted RCTs of the efficacy of mobilization in combination with other physiotherapeutic modalities in WAD. 9, 10, 62, 63, 64 McKinney et al 62 found that one week after completion of a two-week course of physiotherapy (including mobilization by McKenzie and Maitland techniques in combination with passive modalities, analgesics and collars) mobilized subjects (physiotherapy group) showed significantly greater improvement in summary ROM and pain than did subjects who were prescribed rest, analgesics and soft collars (rest group). The improvement in the physiotherapy group was equivalent to that of subjects who received advice on posture, on early activation, a program of home exercises and a prescription of soft collars and analgesics with advice to limit use of both. A follow-up at two years after completion of treatment showed that the physiotherapy group and rest group had similar proportions recovered (defined as absence of symptoms). 62 The advice group had a significantly higher proportion recovered than either the rest or the physiotherapy group. These results are consistent with the work of Mealy et al, 64 who reported that the Maitland mobilization technique, in combination with passive modalities and advice for home exercises and analgesics, had a significantly better short-term effect on pain and ROM than the prescription of two weeks rest, soft cervical collar and analgesia in acute WAD. Brodin9,10 found that a three-week course of passive mobilization in combination with a brief information session and analgesics was more effective in reducing pain and improving ROM one week after treatment than was "mock therapy" with education and analgesics, or simply analgesics with instruction to wait for treatment. The duration of symptoms before treatment initiation was not specified in these reports.

The cumulative evidence suggests that mobilization techniques can be used as an adjunct to strategies that promote activation. In combination with activating interventions, they appear to be beneficial in the short term, but long-term benefit has not been established.

3. Exercise: The independent effect of exercise has not been evaluated. Active exercises were included as part of the interventions in the McKinney et al, 62, 63 Mealy et al, 64 Foley-Nolan et al28 and Zybergold and Piper 125 trials (See 4. Traction). The cumulative evidence suggests that active exercise as part of a multimodal intervention may be beneficial in the short and long term. This suggestion should be confirmed in future studies.

4. Traction: There was no research found regarding the independent benefit of traction in any grade of WAD. The literature yielded one accepted paper focussed primarily on traction, 125 a RCT in patients with cervical spine disorders including WAD. There were four treatment groups: static traction, intermittent traction, manual traction and control (no traction). All four groups received neck care instruction, moist heat treatments and a program of exercises. For all three types of traction combined, there was a significantly greater change over the control group only in forward flexion and in right rotation. However, there were no clinically or statistically significant differences in ROM change in extension, left or right lateral bending, left rotation, or in change of pain severity. Although the authors advocate intermittent traction, there were no clinically or statistically significant differences in outcome (change in pain by the McGill Pain Questionnaire and ROM at six weeks) between any of the traction types and the control treatment.

5. Postural Alignment and Advice: There was no research found regarding postural alignment. Advice on posture was part of the intervention for the "advice" group in the studies of McKinney et al 62, 63 (see Mobilization above).

6. Spray and Stretch: There were no studies found regarding Spray and Stretch.

Passive modalities/electrotherapies

1. Transcutaneous Electrical Nerve Stimulation (TENS): There were no accepted studies regarding TENS.

2. Pulsed Electromagnetic Treatment (PEMT): There were two accepted RCTs on PEMT, one in neck pain patients 27 and one in patients with WAD Grades I and II referred from an emergency department within 72 hours of a motor vehicle collision (MVC).28 The PEMT device in a soft cervical collar (treatment) was compared with a sham PEMT device in a soft cervical collar (controls). The treatment course was 12 weeks; patients could elect to add physiotherapy beginning at four weeks. The treatment group showed a greater improvement in pain and ROM in the first four weeks than did the control group. Use of analgesics also declined in the PEMT group up to four weeks, but not in the control group. At four weeks, approximately half of each group ( 45% of treatment vs. 60% control group -- not significant by secondary analysis) added physiotherapy to their treatment. After that the control group improved more quickly than the treatment group, so that at 12 weeks there were no differences between the groups. Since the PEMT device is in a soft collar, which tends to encourage inactivity, it cannot be recommended until it is demonstrated superior or at least equivalent to mobilizing interventions.

3. Electrical Stimulation: There were no accepted studies regarding electrical stimulation in WAD.

4. Ultrasound: There were no accepted studies regarding ultrasound in WAD.

5. Laser, Short Wave Diathermy, Heat, Ice, Massage: There were no accepted studies regarding the independent effect of any of these treatments for WAD or neck pain. They were part of the combination of passive modalities in the studies of McKinney et al, 62, 63 Mealy et al 64 and Brodin. 9, 10

Surgical treatment

There were no accepted studies of disc surgery or nerve block in WAD or cervical disorders. No research was found concerning the benefit of rhizolysis in WAD.

Injections

No accepted studies were found addressing epidural or intrathecal steroid injections for WAD. Accepted studies were found addressing intraarticular steroid injections for chronic WAD (one study) 4 and subcutaneous sterile water trigger point injections for chronic neck and shoulder pain (one study). 12 The results from these studies are summarized below.

1. Intraarticular steroid injection: Injection with betamethasone (treatment group) were no better than 0.5% bupivacaine (control group) for relief of cervical zygapophysial joint pain of greater than three-months duration attributed to a motor vehicle collision. 4 The short duration of pain relief overall and the lack of a substantial difference in duration of efficacy between steroid and local anesthetic, leads to the conclusion that intraarticular steroid injection is not justified in the treatment of cervical zygapophysial joint pain after whiplash injury.

2. Subcutaneous sterile water injection: One accepted RCT,12 conducted in patients with chronic neck and shoulder pain four to six years after whiplash injury, found a greater improvement in reported pain and cervical ROM in patients receiving sterile water injections compared to patients receiving saline injections. A major limitation of this study is the lack of blinding. The immediate pain associated with sterile water injection is such that neither patients nor treating physicians were blind to the treatment received.

Pharmacologic interventions

No research was found regarding the benefit of narcotic analgesics or psychopharmacologic therapeutics in WAD.

Analgesics 9, 62, 63, 64 and NSAIDS 27, 28 in combination with other treatment modalities were associated with short-term benefit for WAD I and II presenting in the acute phase or less than 72 hours post-collision.

No accepted studies were found regarding muscle relaxants in WAD.

Psychosocial interventions

No research was found regarding the psychosocial interventions in WAD.

Other interventions

Among all the other interventions cited, there were accepted studies for only three.

1. Prescribed Function: In a RCT of the efficacy of prescribed function within 72 hours of a MVC in Grade I and II WAD, McKinney et al 62, 63 found that advice to mobilize, exercise, limit inactivity and avoid dependence on collars and analgesics was effective. This regimen of prescribed function was at least as effective in improving cervical ROM in the short term, and more effective in improving symptoms in the long term, than physiotherapy that included McKenzie and Maitland mobilization techniques.

2. Acupuncture (formally prescribed): No research was found concerning acupuncture in WAD. One study was accepted comparing acupuncture to sham transcutaneous electrical nerve stimulation (TENS) in rheumatology outpatients with chronic neck pain of at least six-months duration. 78 Acupuncture was not demonstrated to be superior to sham TENS. Since this study was not conducted in patients with WAD, the efficacy of acupuncture for treatment of WAD remains to be established.

3. Magnetic Necklace (not formally prescribed): There was one accepted study regarding the efficacy of the magnetic necklace in chronic neck pain. 44 Patients with neck and shoulder pain for more than one year were randomly assigned to active or sham magnetic necklace. There were no differences in reported pain or other outcomes between the two groups at baseline examination and after three weeks of treatment.

Although there were no accepted studies supporting its efficacy in any grades of WAD at any time, the magnetic necklace appears to be widely advertised in the lay media. It is not common practice among mainstream health-care providers.