Guidelines for the Management of Whiplash Associated Disorders

8/12/2019 Guidelines for the Management of Whiplash Associated Disorders

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January 2001

G uidelines for the M anagement of

Whiplash-Associated Disorders


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contents

Preface 4

Flow chart of guidelines 6

Notes to accompany flow chart 7

Summary of recommendations

for clinical practice 8

Diagnosis 8

Prognosis 10

Treatment 11

Purpose of the guidelines 14

Definition of condition and

scope of the guidelines 14

Methodology 16

Recommendations

for clinical practice 18

Diagnosis 18History taking 18

Physical examination 20

Plain radiographs 21

Specialised imaging techniques 22

Specialised examinations 23

Prognosis 24

Symptoms 24

Radiological findings 24

Psychosocial factors 25

Socio-demographic factors 25

Treatment 26

Recommended 26

Reassure 26

Act as usual 26

Miscellaneous interventions

- prescribed function, work

alteration, acupuncture and

relaxation techniques 27

Manual and physical therapies

- exercise 27Pharmacology 28

Recommended under certain

circumstances 30


- postural advice 30

- mobilisation 30

- manipulation 31

- traction 31Multimodal 32

Acupuncture 33

Passive modalities/electrotherapies

- heat, ice, massage, TENS, PEMT,

electrical stimulation, ultrasound,

laser, short-wave diathermy 33

Immobilisation - prescribed rest, collars 34

Surgical treatment 35Not recommended 36

Immobilisation - cervical pillows 36


- spray and stretch 36

Injections - steroid injections 36


- magnetic necklaces 37

Other interventions- e.g. Pilates, Feldenkrais, Alexander

Technique, massage, homeopathy 37

Not relevant to treatment of acute

WAD Grades I, II or III 38

Injections - sterile water injections,

local anaesthetic or nerve blocks 38

The Working Party 39

Glossary 41

Notes 43


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Guidelines for the Management of

Whiplash-Associated Disorders


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Preface

In October 1999 new legislation was enactedgoverning the operations of the New South

Wales Motor Accidents Authority (MAA) and theCompulsory Third Party (CTP) insurancescheme it administers.

One aim of the legislative change under theMotor Accidents Compensation Act 1999 is toimprove the capacity of the scheme to ensurethat reasonable and necessary care isdelivered to people with injuries and illnessfollowing motor vehicle accidents.

Changes made to the scheme are intended toimprove the quality of medical assessments andensure that care provided is consistent with thebest available knowledge of appropriate andeffective diagnosis, treatment, rehabilitation andongoing support.

The legislation introduces these changes:

New procedures for resolving disputes aboutmedical and rehabilitation issues, wherepossible based on the principles ofevidence-based medicine.

Medical assessors from a range of healthbackgrounds to resolve medical disputes.

New guidelines for the assessment of

permanent impairment. New guidelines for the appropriate treatment,

rehabilitation and care of injured persons.

Whiplash-Associated Disorders (WAD) is thesingle most frequently recorded injury amongstCTP claimants in NSW. It was a factor in 38.9%of claims and responsible for 25% of costs in1998.

As an interim measure, the MAA accepted aproposal to update the Quebec Task Force(QTF) guidelines. This method offered a

practical, cost-effective and immediate way tomove ahead on the issue. Looking ahead, theNational Musculoskeletal Initiative is expected

to deliver more comprehensively evidence-based recommendations for the management of

this condition in the future.The Quebec Task Force on Whiplash-AssociatedDisorders1 was convened as a result of theQuebec Automobile Insurance Society requestfor an in-depth analysis of clinical, publichealth, social and financial determinants of the

whiplash problem. The QTF focused onclinical issues, specifically risk, diagnosis,treatment and prognosis of whiplash. Duringdevelopment of the guidelines, the QTFreviewed 10,000 publications. In addition, acohort of whiplash subjects from the injury

claim files of the Quebec Automobile InsuranceSociety was identified and prognostic factors inthe recovery process were examined. The QTFreleased its findings in a scientific monographin April 1995.

In general, the available evidence was foundto be sparse and of poor quality. While theQTF would have preferred to base therecommendations on research findings, it wasnecessary to develop the guidelines largely onconsensus and the expert knowledge ofmembers of the QTF who were drawn from

many clinical fields. Despite uncovering somenew evidence, the same problem has faced the

Working Party preparing these guidelines fiveyears later.

In these guidelines, changes to therecommendations of the QTF have been basedon available new evidence published since theQTF literature review. Where publishedevidence is lacking or inconsistent, a consensusof the Working Party (i.e. majority view of allmembers) is given. When making itsrecommendations, the Working Party also took

into account comment received during abroader consultation and reviews by threeexperts.

There is potentially great benefit in agreeing on effective ways to manage acute

Whiplash-Associated Disorders. Consequently, the MAA decided to take on the task

of developing guidelines for the management of Whiplash-Associated Disorders.

1 See Notes, page 43


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The MAA is aware that the work of the QTF hasbeen criticised,2 with major criticisms being:

the work is largely consensus based ratherthan evidence based (due to lack ofevidence)

selection criteria for the literature review werenot clear and some evidence, which indicatedthat studies demonstrating WAD to be otherthan a self-limiting condition of temporarydiscomfort and no permanent harm, wasexcluded (i.e. selection bias).

The criticism of a bias towards viewing WAD asa self-limiting condition was noted and does notaffect the recommendations on diagnosis andtreatment which form the substance of theseguidelines. The guidelines recognise that thenatural course of the condition can go beyondthe acute phase addressed here.

While acknowledging these criticisms, the MAAaccepted that other experts in this area view theQTF guidelines as the first ever systematic

review of the world literature on whiplashwhich established the baseline scientificknowledge in this subject area and created thefirst evidence-based patient care guidelines.3

Clinical utility has been uppermost in the mindsof the team working on this project. The MAAhopes that the guidelines will be useful toprimary care practitioners, consumers and theinsurance industry.

These guidelines are to cover the first 12 weeksfollowing the motor vehicle accident.

Of course, these guidelines only offer a startingpoint. It is important to encourage practitionersto consult the guidelines and to ask for theirfeedback. Rather than perfecting the guidelinesin theory, the MAA has planned a strategy topublish, distribute and test these guidelines inNew South Wales.

2, 3 See Notes, page 43


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These are guidelines only.

There will be individual variations.GPs should reassess patients regularly, at leastat the intervals on the flow chart.

Consultations should include an assessment asto whether patients are gaining improvementfrom therapy programs, including those beingdelivered elsewhere, e.g. physical or manualtherapy. If improvement is not evident, GPsshould consider liaising with the therapist orcurtailing that treatment.

Usually, referral for physical therapy or manualtherapy is not required for the first few days,but if required, should commence within sevendays.

Whole person treatment includes managing anyaccompanying anxiety and/or depression thatmay be associated with WAD or with otherstressful life events.

WAD Grade I has been considered separatelyfrom WAD Grades II and III as more expedientresolution is expected. Also, referral isrecommended earlier for unresolving cases,especially if psychosocial factors appear to bedelaying recovery.

If the patient presents with any known adverseprognostic indicators (yellow flags), the

potential for more intensive treatment and/orreferral should be considered.

An ever-present problem in managingWhiplash-Associated Disorders as recommendedin this flow chart is possible delay between thetime of requesting an appointment with aspecialist, multi-disciplinary pain orrehabilitation team and the subsequent date ofthe appointment. One solution, especially forcases with adverse prognostic indicators (yellowflags), would be to make a provisionalappointment before the need is urgent. GPs andspecialists could negotiate an arrangement thatenables the appointment to be cancelled if notrequired.

These guidelines cover the management of

WAD Grades I to III in the acute and sub-acutephases, up to around three months from injury.The exit points from here are indicated in theflow chart by a dark blue box. These are:

referral to a multi-disciplinary pain team orrehabilitation provider for WAD Grade I for acase which is not resolving after six weeks

referral to a multi-disciplinary pain team orrehabilitation provider for WAD Grades IIand III for a case which is not resolving at12 weeks

referral to A&E or a specialist surgeon for

WAD Grade IV.

Yellow Flags4

If one or more of the following adverse prognosticindicators are present, more intensive treatmentand/or earlier referral may be required.

Severity of neck symptoms and radicularirritation

Presence of specific symptoms such as headache;

muscle pain; pain or numbness radiating fromneck to arms, hands or shoulders

More initial subjective complaints and concernregarding long-term prognosis

Multiple initial symptoms

Older age

Female gender

Not in full-time employment

Having dependants

Presence of osteoarthritis on X-ray

Notes to accompany flow chart



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History taking

History taking is important during all visits forthe treatment of WAD patients of all grades.

The history should include information about:

date of birth, gender, occupation, number ofdependants, marital status

prior history of neck problems includingprevious whiplash injury

prior history of psychological disturbance

prior history of long-term problems inadjusting to symptoms of an injury or illness

current psychosocial problems, e.g. family,job-related, financial problems

symptoms including pain, stiffness, numbness,weakness and associated extracervicalsymptoms localisation, time of onset andprofile of onset should be recorded for allsymptoms

circumstances of injury (sport, motorvehicle); mechanism of injury, e.g. if the

head moved forwards, backwards, sidewaysor all of these; how the accident occurred;the position of the person in the car, i.e.passenger or driver; body position; type of

vehicle involved

results of assessments conducted using toolsto measure general psychological state andpain and disability outcomes, e.g., theGeneral Health Questionnaire (GHQ), a visualanalogue pain scale or a neck disabilityindex examples of these are available fromthe MAA.

History details should be recorded. A standardform may be used.

Physical examination

A focused physical examination is necessaryfor all patient visits. The physical examinationshould include at least:

inspection

palpation for tender points

ROM in flexion-extension, rotation and lateralflexion

neurological examination to assess

sensorimotor function and tendon reflexes ofupper and lower limbs

assessment of associated injuries

assessment of general medical condition asneeded, including mood, affect andpsychological state.

A universal goniometer can be used to measureneck ROM, and/or a hand-held dynamometercan be used to measure strength.

Both positive and negative findings should berecorded. A standardised form may be used.

Plain radiographs

WAD Grade IWAD Grade I patients do not require a plainradiograph on presentation if they:

are conscious

show no signs of alcohol-related impairment

are not obtunded by narcotics or other drugs

show no physical signs on examination, havenot been involved in a high speed or high

impact injury, or in a collision where anotheroccupant has been killed.

Diagnosis of Whiplash-Associated Disorders

Summary ofrecommendations for clinical practice

This section summarises the recommendations for clinical practice.

For information about how these recommendations were made, see Methodology,

page 16, and Recommendations for Clinical Practice, page 18.


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WAD Grade IIIn patients presenting as WAD Grade II, plain

X-rays of the cervical spine should be taken if:

the severity of the signs on examinationsuggest the possibility of a bony injury

their level of consciousness or pain sensationis impaired by brain injury or alcohol or otherdrugs

they have been involved in high speed orhigh impact injury, or in a collision whereanother occupant has been killed.

Flexion and extension views may occasionallybe indicated.

WAD Grade IIIAll patients who present with WAD Grade IIIshould have baseline radiological investigationof the cervical spine including anterior-posterior, lateral and open-mouthed views. Allseven cervical vertebral and the C7-T1 discshould be well visualised. Flexion-extension

views may occasionally be indicated.

Specialised imaging techniques

WAD Grades I and IIThere is no role for specialised imagingtechniques (e.g. tomography, CAT scan, MRI,myelography, discography etc.) in WAD GradesI and II.

WAD Grade IIISpecialised imaging techniques might be usedin selected WAD Grade III patients, e.g. nerve

root compression or suspected spinal cordinjury, on the advice of a medical or surgicalspecialist.

Specialised examinations

Specialised examinations were considered bythe Working Party as not relevant tomanagement of WAD Grades I to III. Examplesinclude EEG, EMG and specialised peripheralneural tests.


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Symptoms

Poor outcome has been associated with:

severity of neck symptoms and radicularirritation at initial assessment

presence of specific symptoms such asheadache; muscle pain; pain or numbnessradiating from neck to arms, hands or

shoulders history of pre-traumatic headaches

previous history of head injury

initial injury reaction (sleep disturbance,nervousness)

more initial subjective complaints andconcern regarding long-term prognosis

pre-existing osteoarthritis

head rotated or inclined at time of impact;occupancy in truck/bus; being in head-on orperpendicular collision.

Identification of these yellow flag factors should alert thepractitioner to the potential need for more intensive treatmentor earlier referral.

Radiological findings

Poor outcome may be associated with pre-existing osteoarthritis on the initial cervicalradiograph.

This yellow flag factor should alert the practitioner to thepotential need for more intensive treatment or earlier referral.

Psychosocial factors

Poor outcome may be associated with:

prior history of psychological disturbance these disturbances may be indicative of aproneness to emotional/affective problemsand somatisation reactions, which arefrequently based on affective disorders;

somatisation reaction in the course of WADmay establish a basis for symptomaugmentation; without early identification andproper treatment, this condition may lead todelayed recovery

prior history of long-term problems inadjusting to symptoms of an injury or illness,e.g. coping mechanisms

current psychosocial problems, e.g. family,job-related, financial problems.

These yellow flag factors should alert the practitioner to thepotential need for more intensive treatment or earlier referral.

Socio-demographic factors

In addition to the fact that management of thiscondition, by definition, is taking place in thecontext of compensation (recognised as anadverse prognostic indicator), other socio-demographic indicators associated with pooroutcome are:

older age

female gender

not in full-time employment

having dependants.


Prognosis of Whiplash-Associated Disorders

Summary of recommendations (continued)


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Treatment of Whiplash-Associated Disorders

Reassure

The practitioner should reassure the patient by acknowledging that the patient is hurt andhas symptoms, and advising that:

symptoms are a normal reaction to being hurt it is important to focus on improvements in

function

maintaining life activities is an importantfactor in getting better.

Act as usual

Act as usual should be used as a treatment forWAD with or without pain relief as perrecommendations regarding pharmacology.

Miscellaneous interventions -prescribed function, work alteration

and relaxation techniques

Prescribed function, i.e. return to usual activityas soon as possible, is recommended.Rehabilitation programs which may include

work alteration and relaxation techniques, mayassist recovery depending on symptoms (e.g.pain, ability to concentrate) and psychosocialfactors.


- exercise

ROM exercises, muscle re-education and lowload isometric exercise to restore appropriate

muscle control and support to the cervicalregion should be implemented immediately, ifnecessary in combination with intermittent rest

when pain is severe. Clinical judgment is crucialif symptoms are aggravated.

Pharmacology

WAD Grade INo medication should be prescribed other thansimple analgesics.

WAD Grades II and IIINon-opioid analgesics and NSAIDs can be usedto alleviate pain for the short term. Their useshould be limited to three weeks and weighedagainst possible side effects.

Opioid analgesics are not recommended forWAD Grades I and II. They may be prescribedfor pain relief in acute severe WAD Grade IIIfor a limited period of time.

Generally, muscle relaxants should not be usedin acute phase WAD.

Psychopharmacologic drugs are notrecommended in WAD of any duration orgrade; however, they may be used occasionallyfor symptoms such as insomnia or tension, oras an adjunct to activating interventions in theacute phase (less than three months duration).

Use of high dose IV methylprednisoloneinfusion for acute management of WAD GradesII and III is not recommended.

Recommended


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Summary of recommendations (continued)

12


- postural advice

Postural advice can be given in combinationwith manual and physical therapies andexercise in WAD.

- mobilisation

Mobilisation can be used for WAD, providingthere is evidence of continuing improvement

with the treatment. If mobilisation is used itshould be commenced early, within the firstseven days. This technique should be restrictedto registered health practitioners5 trained in thespecific methods and according to currentprofessional standards.

- manipulation

A regime of manipulation can be used for WAD,

providing there is evidence of continuingimprovement with the treatment. This techniqueshould be restricted to registered healthpractitioners trained in the specific methods andaccording to current professional standards.5

Complications from manipulation are rare, butinclude stroke and death. WAD Grade III(decreased or absent deep tendon reflexesand/or weakness and sensory deficit) is arelative contra-indication for manipulation.

- traction

A regime of traction can be used incombination with other mobilising modalities in

WAD providing there is evidence of continuingimprovement with the treatment.

Multimodal

A multimodal treatment program can be usedfor WAD that has not settled within four to six

weeks providing there is evidence of continuingimprovement with the treatment.

Acupuncture

A regime for acupuncture can be used in WADproviding there is evidence of continuingimprovement with the treatment.



electrical stimulation, ultrasound, laser,short-wave diathermy

WAD Grade IAlthough active PEMT in a soft collar is betterthan sham PEMT in a soft collar, PEMT is notrecommended because it involves wearing asoft collar eight hours/day for 12 weeks.

WAD Grades II and IIIDuring the first three weeks, other

professionally administered passivemodalities/electrotherapies are optional adjunctsto manual and physical therapies and exercise.Emphasis should be placed on return to usualactivity as soon as possible.

Immobilisation - prescribed rest

WAD Grade IRest is not recommended for WAD Grade I.

WAD Grades II and III

Rest for more than four days is notrecommended for WAD Grades II and III.

Immobilisation - collars

WAD Grade ICollars are not recommended for WAD Grade I.

WAD Grades II and IIIIf prescribed for WAD Grade II or III, theyshould not be used for more than 72 hours.

Recommended under certain circumstances



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Purpose of the guidelines

The guidelines are intended to assist health professionals delivering primary care

to adults with acute or sub-acute simple neck pain after motor vehicle collisions,

in the context of third party insurance compensation.

Definition of condition and scope of the guidelines

Definition

The QTF6 definition of Whiplash-AssociatedDisorders (WAD) has been adopted as thedefinition of acute or sub-acute simple neckpain for the purposes of these guidelines.

Whiplash is an acceleration-deceleration

mechanism of energy transfer to the neck.

It may result from ...motor vehicle

collisions... The impact may result in bony

or soft tissue injuries,7

which in turn maylead to a variety of clinical manifestations

(Whiplash-Associated Disorders).

Scope

The scope of the guidelines covers WAD GradesI, II and III following a motor vehicle collision.

These guidelines are applicable in the firsttwelve weeks when WAD is the only injury or

when it has occurred concurrently with otherinjuries.

Grades of WAD

The following clinical classification provided bythe QTF is noted.

Symptoms and disorders that can be manifest inall grades include deafness, dizziness, tinnitus,headache, memory loss, dysphagia andtemporomandibular joint pain.

Grade Classification

0 No complaint about the neck.No physical sign(s).

I Neck complaint of pain, stiffness ortenderness only.No physical sign(s).

II Neck complaint ANDmusculoskeletal sign(s).Musculoskeletal signs includedecreased range of motion and pointtenderness.

III Neck complaint AND neurologicalsign(s).Neurological signs include decreasedor absent deep tendon reflexes,

weakness and sensory deficits.8

IV Neck complaint ANDfracture or dislocation.

6, 7, 8 See Notes, page 43


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When to consult the guidelines

An example of appropriate use of theguidelines is a situation in which an adult whois experiencing neck pain after a recent motor

vehicle collision consults his or her generalpractitioner. The guidelines would be relevantduring the period when the doctor:

takes a history

conducts an examination

determines what, if any, investigations are

required, and treats or refers for treatment from other health

professionals such as physiotherapists andchiropractors.

In many cases, recovery from WAD occursquickly; however, it is recognised that somepeople with WAD will require treatment andsupport beyond 12 weeks.

To deal with more complex cases the guidelinesoffer ways to take action, by:

alerting primary health care professionals to

adverse prognostic indicators (yellow flags)which may indicate the need for moreintensive treatment or early referral.

confirming that the diagnosis of a fracture ordislocation warrants immediate referral to an

Accident and Emergency Department or aspecialist surgeon.

providing indications of durations whenreferral to specialists or multi-disciplinary painteam or rehabilitation providers should beconsidered.

Target audience and products

The primary target audience for the clinicalpractice guidelines is general practitioners inNew South Wales. The guidelines will berelevant to other health professionals involvedin primary care in New South Wales, e.g.physiotherapists, chiropractors and osteopaths.

Companion documents have also beendeveloped for consumers, and for claimsofficers in the compulsory third party insuranceindustry in New South Wales.

A technical report containing the tables ofevidence and a detailed description of themethodology used to adapt the QTF guidelinesfor use in New South Wales has also beenprepared.

Titles of the five documents are as follows:

Guidelines for the Management ofWhiplash-Associated Disorders forhealth professionals.

SUMMARY Guidelines for the Management ofWhiplash-Associated Disorders.

Your Guide to Whiplash Recovery forconsumers.

Compulsory Third Party Claims Guide to theManagement of Whiplash-Associated

Disorders for the compulsory third partyinsurance industry.

TECHNICAL REPORT Update of QTFGuidelines for the Management of Whiplash-

Associated Disorders.

Copies are available from the Motor AccidentsAuthority.


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The methodology was guided by NationalHealth and Medical Research Councilrecommendations9 for the development ofclinical practice guidelines. The followingapproach was taken:

Recommendations contained in the guidelinesdeveloped by the QTF and published in 1995

were taken as the starting point.

A literature review was undertaken to collectinformation on additional evidence which

was both relevant to the scope of theseguidelines and which had been publishedafter the evidence was collected by the QTF(i.e. after 1993). The NHMRCrecommendations for the review of evidenceare summarised on the next page.

Tables of evidence were prepared which:

summarise the literature identified, and

rate the new evidence provided by thereview: from I, the highest quality, to IV,the lowest quality. In rating the evidencethe Working Party was guided by NHMRCrecommendations, summarised on thenext page.

QTF recommendations were reviewed in thelight of this evidence, and in the absence of

any further evidence, the opinion of theTechnical Group, a sub-set of the WorkingParty. Criteria taken into account in makingthese recommendations were: opinion onefficacy and safety.

The draft developed by the Technical Groupwas reviewed by the broader Working Party.

The draft clinical guidelines were then sentout to a range of medical and healthorganisations and individuals for comment.

Consultations on the draft clinical guidelineswere undertaken with industry representativesand consumers in order to developcompanion documents for claims managers inthe compulsory third party insurance industryand for consumers.

The clinical guidelines were substantiallyreworked in the light of public comment.Changes included:

providing more information about thestanding of the QTF guidelines, includingcriticisms

providing more information on the basisfor changes made to the QTF

recommendations improving the layout of the document to

make it easier for primary health carepractitioners to use

modifying some recommendations.

The four documents were then sent to threeexperts for review two reviewers overseasand one in Australia.

Overall the comments of the reviewers werepositive. Further changes made to incorporatereviewers comments were:

providing more information about thelimitations of the QTF guidelines

adding a recommendation that patientsshould be reassured as part of theirtreatment

recommending that psychological andpsychosocial factors should be recorded aspart of history taking and added asprognostic indicators

recommending rehabilitation programs forthose unable to return immediately to theirusual activities.

Methodology

A detailed account of the process by which these consensus guidelines were

developed is described separately in Technical Report: Update of Quebec Task

Force Guidelines for the Management of Whiplash-Associated Disorders.



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Key characteristics of this approach:

Clearly stated title and objectives for thereview.

Comprehensive strategy to search for studiesthat address the objectives of the review(relevant studies) to include unpublished as

well as published studies.

Explicit and justified criteria for theinclusion or exclusion of any study.

Comprehensive list of all studies identified.

Clear presentation of the characteristics ofeach study included and an analysis of

methodological quality. Comprehensive list of all studies excluded

and justification for exclusion.

Clear analysis of the results of the eligiblestudies using statistical synthesis of data(meta-analysis), if appropriate and possible.

Sensitivity analyses of the synthesised data ifappropriate and possible.

Structured report of the review clearlystating the aims, describing the methods andmaterials and reporting the results.

NHMRC methodology for review

of evidence

Grade I

Evidence obtained from a systematic reviewof all relevant randomised controlled trials.

Grade IIEvidence obtained from at least one properlydesigned randomised controlled trial.

Grade III-1Evidence obtained from well-designedpseudo-randomised controlled trials.

Grade III-2Evidence obtained from comparative studies

with concurrent controls and where

allocation is not randomised (cohort studies),case-control studies, or interrupted timeseries with a control group.

Grade III-3Evidence obtained from comparative studies

with historical control, two or more single-arm studies, or interrupted time series

without a parallel control group.

Grade IVEvidence obtained from a case series, eitherpost-test or pre-test and post-test.

NHMRC rating scale for quality

of evidence

The four documents were then sent as finaldrafts to the MAA Advisory Council forapproval.

During the period of public comment andexpert review an implementation andevaluation strategy was developed.


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History taking

Recommendations for clinical practice

The Working Party recommendations for clinical practice are presented by subject,

with the original Quebec Task Force recommendation, its basis, and an explanation

of any change to that recommendation.

Additional evidence located by the literaturereview covering 1993 to 1999 in relation to this

subject is then summarised and the level ofevidence provided by this research is rated.

The Technical Report, also published by theMAA, provides titles and further details of

these studies.Finally there is a justification for any changesmade to the QTF recommendation.

Diagnosis of Whiplash-Associated Disorders

History taking is important during all visits for the

treatment of WAD patients of all Grades.


date of birth, gender, occupation, number of

dependants, marital status

prior history of neck problems including previous

whiplash prior history of psychological disturbance

prior history of long-term problems in adjusting

to symptoms

current psychosocial problems, e.g. family, job-

related, financial problems

symptoms including pain, stiffness, numbness,

weakness and associated extracervical symptoms

localisation, time of onset and profile of onset

should be recorded for all symptoms

Working Party recommendationsfor clinical practice

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

anism of injury, e.g. if the head moved

forwards, backwards, sideways or all of these; how

the accident occurred; the position of the person in

the car, i.e. passenger or driver; body position; type

of vehicle involved

results of assessments conducted using tools to

measure general psychological state and pain and

disability outcomes, e.g. the General Health

Questionnaire (GHQ), a visual analogue pain scale

or a neck disability index; examples of these areavailable from the MAA.

History details should be recorded. A standard form

may be used.

Quebec Task Force (QTF) recommendations for

clinical practiceHistory taking is important during all visits forthe treatment of WAD patients of all Grades.


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date of birth, gender, occupation, number ofdependants and marital status

prior history of neck problems, includingprevious whiplash

symptoms including pain, stiffness, numbness,weakness and associated extracervicalsymptoms

circumstances of injury (e.g. sport, motorvehicle) and

mechanism of injury.

This minimal history should be recorded on astandard form.

Basis of QTF recommendationsTwenty studies dealing with aspects of thepatient history in diagnosis of WAD werereviewed. No accepted study dealt with the

value of history taking for the positive diagnosisof WAD.

These recommendations are based on theconsensus of the Task Force.

Additional evidenceNo additional study was identified that dealt

with the value of history taking for positivediagnosis of WAD.

There are cohort studies considering prognosticindicators of WAD that are relevant to historytaking (see below for details of studies). Pooroutcome/delayed recovery has been associated

with several variables including:

severity of neck symptoms and radicular

irritation at initial assessment (Radanov BP,1994 and 1995)

presence of specific symptoms such asheadache; muscle pain; pain or numbnessradiating from neck to arms, hands orshoulders (Radanov BP, 1994)

history of pre-traumatic headaches or pasthead injury (Radanov BP, 1994 and 1995)

initial injury reaction (sleep disturbance,nervousness) (Radanov BP, 1994)

more initial subjective complaints andconcern regarding long-term prognosis

(Radanov BP, 1995)

pre-existing osteoarthritis (Radanov BP, 1995)

older age (Harden S et al., 1998; Hartling L etal., 1999; Smed A, 1997; Radanov BP, 1994and 1995)

female gender (Harden S et al., 1998; SmedA, 1997)

not in full-time employment (Harden S et al.,1998)

having dependants (Harden S et al., 1998)

insurance/compensation presence of; typeof system (Cassidy D et al., 1999)10

head rotated or inclined at time of impact

(Radanov BP, 1995; Haden S et al., 1998);occupancy in truck/bus; being in head-on orperpendicular collision (Radanov BP 1995)

pre-traumatic headaches (Radanov B P, 1994and 1995)

previous history of head injury (Radanov BP,1994).

Evidence of psychosocial factors was conflicting(Radanov BP 1994 and 1995; Karlsbourg et al.,1997; Heikkila H et al., 1998). Cassidy (1999)found that the incidence rate of claims was less

in a no fault scheme compared to a tort scheme.Rating of additional evidence: III2 for adverseprognostic indicators.

Noted that for research on prognosis a well-designed cohort study is the highest possiblelevel of evidence.

Basis for changes to QTF recommendationsBy consensus of the Working Party, reference to

validated tools for measuring pain and neckdisability was added in response to public

comment. By consensus of the Working Partypychosocial factors (prior history ofpsychological disturbance, prior history of long-term problems in adjusting to symptoms andcurrent psychosocial problems, e.g. family, job-related, financial problems) and examples ofmechanism of injury were included in responseto comment from an expert reviewer. As well it

was stated that a standardised form may beused rather than should be used.



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Physical examination

QTF recommendations for clinical practiceA focused physical examination is necessaryduring all patient visits. The physicalexamination should include at least:

inspection


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

neurological examination to assesssensorimotor function and tendon reflexes ofupper and lower limbs


assessment of general medical condition, asneeded.

Results of the minimal physical examination

should be recorded on a standard form.

Basis of QTF recommendationsEighteen studies dealing with aspects ofphysical examination of WAD patients werereviewed. No accepted study dealt with the

value of physical examination for the positivediagnosis of WAD.

These recommendations are based on theconsensus of the Task Force.

Additional evidenceNo accepted additional study was identified that

dealt with the value of physical examination forthe positive diagnosis of WAD.

There are cohort studies considering prognosticindicators of WAD that are relevant to physicalexamination. One cohort study of 50 patientspresenting to an accident and emergencydepartment found that a diminished range ofneck movements and poor psychological state,as measured by the General HealthQuestionnaire (GHQ 28), at three months waspredictive of intrusive or disability symptoms attwo years (Gargan M et al., 1997). In one

seven-year cohort study of 2,627 subjects,authors concluded that patients presenting withseveral specific musculoskeletal (neck pain onpalpation) and neurological signs andsymptoms may have a longer recovery period(Suissa S, 1999).

Rating of additional evidence: IV for tendernessto palpation, neurological signs, ROM andpsychological state.

Basis for changes to QTF recommendations

Mood, affect and psychological state wasadded to physical examination on the basis oflevel IV evidence. In response to publiccomment the Working Party agreed to includereference to the use of goniometers anddynamometers. As well it was stated that astandard form may be used rather thanshould be used.

The addition of the phrase both positive andnegative findings before should be recorded

was based on the comments of an externalreviewer and Working Party consensus.

A focused physical examination is necessary for all

patient visits. The physical examination should include

at least:

inspection


ROM in flexion-extension, rotation and lateral flexion

neurological examination to assess sensorimotor func-

tion and tendon reflexes of upper and lower limbs


assessment of general medical condition as needed,

including mood, affect and psychological state.

a universal goniometer can be used to measure

neck ROM, and/or a hand-held dynamometer can

be used to measure strength.

Both positive and negative findings should be

recorded. A standard form may be used.

Working Party recommendations

for clinical practice

Recommendations for clinical practice (continued)


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21

Plain radiographs

QTF recommendations for clinical practiceAll patients who present with WAD Grades IIand III should have baseline radiologicalexamination of the cervical spine. Thisexamination should include anteroposterior,

lateral and open-mouth views. All sevencervical verterbral and the C7-T1 disc spaceshould be well visualised.

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

WAD Grade I patients who are conscious, showno evidence of alcohol-related impairment, arenot obtunded by narcotics or other drugs, and

who show no physical signs on examination,require no plain radiographs on presentation.

Basis of QTF recommendationsSixty-one studies dealing with plain radiographsin WAD patients were reviewed. No accepted

study dealt with the value of plain radiographsfor the diagnosis of WAD.

Plain radiographs are not useful for thediagnosis of WAD Grades I, II and III.Radiographs are needed to diagnose bonylesions of WAD Grade IV. There is suggestion inthe literature that patients with WAD Grade Iand no other injury, with no midline cervicalpain, with normal alertness and attention, and

who are not obtunded by narcotics, alcohol, orother drugs, may not need radiographs. Thesmall sample size of these studies and the

resulting uncertainty around estimates of falsenegative and positive rates made it impossibleto make recommendations about plainradiographs on the basis of scientific data.

Recommendations regarding plain radiographsin diagnosis of WAD are based on theconsensus of the Task Force.

Additional evidenceNo accepted additional study was identified thatdealt with the value of plain radiographs for thepositive diagnosis of WAD.

With regard to usefulness of plain radiographs,there was one observational study of 669subjects where authors concluded that in theabsence of very high force/speed impacts,clinicians should feel safe in assessing patientsinvolved in rear-end MVCs without the use of

X-rays (Brison R et al., 1999). A cohort study of117 subjects identified that poor outcome wasassociated with more signs of pre-existingcervical spine osteoarthritis on initial X-ray(Radanov BP 1995). In another cohort study of100 subjects authors concluded that kyphoticangle seen on functional views does not indicatesoft tissue injury (Ronnen HR et al., 1996).

WAD Grade IWAD Grade I patients who are conscious, show no

signs of alcohol-related impairment, are not obtunded

by narcotics or other drugs, who show no physicalsigns on examination, have not been involved in a

high speed or high impact injury, or in a collision

where another occupant has been killed, require no

plain radiograph on presentation.

WAD Grade IIIn patients presenting as WAD Grade II, plain X-rays

of the cervical spine should be taken if the severity

of the signs on examination suggest the possibility of

a bony injury, or if their level of consciousness, or

pain sensation is impaired by brain injury or alcohol

or other drugs, or if they have been involved in high

speed or high impact injury, or in a collision where

another occupant has been killed. Flexion and

extension views may occasionally be indicated.

WAD Grade IIIAll patients who present with WAD Grade III should

have baseline radiological investigation of the cervical

spine including anterior-posterior, lateral and open-

mouthed views. All seven cervical vertebral and theC7-T1 disc should be well visualised. Flexion-extension

views may occasionally be indicated.




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22

Plain radiographs (continued)

Rating of additional evidence: IV for aconservative approach to radiologicalinvestigation.

Basis for changes to QTF recommendationsThe recommendation was re-organised forclarity. The requirement for plain X-rays of thecervical spine for WAD Grade II wasdowngraded to specifying the circumstances in

which this would be required. The basis for this

was level IV evidence. The requirements forradiological investigation for high speed, highimpact collisions, or those where anotheroccupant has been killed, were added forconsistency with the Royal Australasian Collegeof Surgeons guidelines for trauma management.

Specialised imaging techniques

QTF recommendations for clinical practiceThere is no role for specialised imagingtechniques (tomography, CT scan, MRI,myelography, discography, scinigraphy,angiography) in WAD Grades I and IIpatients. Specialised imaging techniques mightbe used in selected WAD Grade III patients

based on the advice of an accredited medical orsurgical specialist.

Basis of QTF recommendationsOne study dealing with tomograms, 10 studiesof CT scan, five studies of MRI, one study ofmyelography, one study of discography, threestudies of scintigraphy, and no studies ofaniography were reviewed.

No accepted studies dealt with CT scans in WADpatients; one study dealt with MRI, but did notprovide any evidence that this technique mightbe useful for the diagnosis of WAD.

Specialised imaging techniques are not useful for

the positive diagnosis of WAD Grades I to III.

Specialised imaging techniques might benecessary, in some instances, to make thepositive diagnosis of WAD Grade IV.

Therefore, these recommendations are based onTask Force consensus.

Additional evidenceOne two-year cohort study of 52 subjectssuggested no benefit in using MRI for commonneck hyperextension-flexion injuries

(Borchgrevink GE et al.,1995). A cohort study of43 subjects over seven months reportedcorrelation between MRI and clinical findings

was poor (Karlsborg et al., 1997). In anobservational study of 39 subjects authorsconcluded that relationship between MRIfindings and the clinical symptoms and signs ispoor (Pettersson K et al., 1998). Anobservational study of 100 acute whiplash injurypatients suggested that there is no role for MRIin routine work-up of acute whiplash injury

when patients have normal radiographs and/or

no evidence of a neurological deficit (RonnenHR et al., 1996).

In conclusion there is evidence (Level IV) toindicate that MRIs are not useful in predictingoutcomes in WAD Grades I to III.

Rating of additional evidence: IV

WAD Grades I and IIThere is no role for specialised imaging techniques

(e.g. tomography, CAT scan, MRI, myelography,

discography etc.) in WAD Grades I and II.

WAD Grade IIISpecialised imaging techniques might be used in

selected WAD Grade III patients, e.g. nerve root

compression or suspected spinal cord injury, on theadvice of a medical or surgical specialist.




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23

Basis for changes to QTF recommendationsThe recommendations were reorganised forclarity. Additional information was provided on

when special imaging techniques might beappropriate to improve usefulness to clinicians.Examples given were based on consensus ofthe Working Party.

Specialised examinations

QTF recommendations for clinical practiceIndications for evoked potentials (SSEP) in WADGrade III patients should be based on the

advice of an accredited medical or surgicalspecialist.

Indications for selective nerve root blocks andof EMG in WAD Grades II and III patientsshould be based on the advice of a medical orsurgical specialist.

Indications for other specialised examinations inWAD patients should be based on the advice ofan accredited medical or surgical specialist.

Basis of QTF recommendationsThe QTF examined one study dealing withevoked potentials (SSEP). No accepted studydealt with evoked potential in WAD.

The QTF examined four studies of selectivenerve root blocks and two studies of EMG.There were no accepted studies of theseexaminations in WAD patients.

The QTF examined five studies ofneurobehavioural tests, six studies of EEG, onestudy of ENG, two studies of other special

audiology or visual examinations. There wereno accepted studies of any of these specialexaminations in patients with WAD.

Therefore all recommendations regarding thesespecialised examinations are based on theconsensus of the Task Force.

Additional evidenceNot included. Not relevant to management of

WAD Grades IIII.

Basis for changes to QTF recommendationsConsidered by Working Party as not relevant tomanagement of WAD Grades IIII. It wasagreed to provide examples of specialisedexaminations EEG, EMG, and specialisedperipheral neural tests.

Considered by Working Party as not relevant to

management of WAD Grades I to III. Examples include

EEG, EMG and specialised peripheral neural tests.



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Symptoms

QTF findingsThree accepted studies provide information onsymptoms that are useful for predictingrecovery. These studies did not cover similarsymptoms and outcome measures. Similarly,only one accepted study provided usefulinformation about signs of prognostic value.Therefore, the QTF recommendations are basedon both evidence and the Task Force consensus.

Additional evidenceSee History taking page 18.

Basis for changes to QTF recommendationLevel III-2 evidence for adverse prognosticindicators (yellow flags). Working Partyconsensus was the basis for adding actionfollowing identification of yellow flag/s.

Radiological findings

QTF findingsAlthough several accepted studies addressedradiological findings, none of the results aredefinitive.

Additional evidenceOne study showed that presence of pre-existingosteoarthritis on the initial cervical radiograph wasa poor prognostic indicator (Radanov BP, 1995).

Rating of additional evidence: IV

Basis for changes to QTF recommendationsLevel IV evidence for adverse prognosticindicator (yellow flag). Consensus of WorkingParty for action following identification of

yellow flag.

Prognosis of Whiplash-Associated Disorders

Poor outcome has been associated with:

severity of neck symptoms and radicular irritationat initial assessment

presence of specific symptoms such as headache;

muscle pain; pain or numbness radiating from neck

to arms, hands or shoulders

history of pre-traumatic headaches

previous history of head injury

initial injury reaction (sleep disturbance,

nervousness)

more initial subjective complaints and concernregarding long-term prognosis

pre-existing osteoarthritis

head rotated or inclined at time of impact;

occupancy in truck/bus; being in head-on or

perpendicular collision.




Poor outcome may be associated with pre-existing

osteoarthritis on the initial cervical radiograph.

This yellow flag factor should alert the practitioner to the

potential need for more intensive treatment or earlier referral.




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Psychosocial factors

QTF recommendations for clinical practiceNot included.

Basis of QTF recommendations

Not included.

Additional evidenceNo additional evidence was found concerningthe independent effect of reassurance on WAD.

Basis for changes to QTF recommendationsConsensus of the Working Party members basedon comments of expert reviewer.

Socio-demographic factors

QTF findingsOf the 11 studies accepted, two provided dataon potential predictive factors.

QTF recommendation is based on both evidenceand the Task Force consensus.

Additional evidenceSee History taking page 18.

Basis for changes to QTF recommendations

Level III-2 evidence for adverse prognosticindicators (yellow flags). Consensus by WorkingParty for action following identification of

yellow flag/s.

In addition to the fact that management of this

condition, by definition, is taking place in the context

of compensation (recognised as an adverse prognostic

indicator), other socio-demographic indicators

associated with poor outcome are:

older age

female gender

not in full-time employment

having dependants




Poor outcome may be associated with:

prior history of psychological disturbance these

disturbances may be indicative of a proneness to

emotional/affective problems and somatisation

reactions, which are frequently based on affective

disorders. Somatisation reaction in the course of

WAD may establish a basis for symptom

augmentation, if not identified early, this is

frequently not treated properly and may lead to

delayed recovery

prior history of long-term problems in adjusting to

symptoms of an injury or illness, e.g. coping

mechanisms

current psychosocial problems, e.g. family, job-related, financial problems.





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26


Reassure


Basis of QTF recommendationsNot included.

Additional evidenceNo additional evidence was found concerning

the independent effect of reassurance on WAD.

Basis for changes to QTF recommendationsConsensus of the Working Party members.

Act as usual



Additional evidenceOne RCT of 201 WAD subjects suggested asignificantly better outcome for the act as usualgroup (self-training and a five-day prescriptionfor NSAIDs) in terms of subjective symptoms incomparison to the other group who wore acollar and were put on sick leave for 14 days(Borchgrevink GE et al., 1995).

Rating of additional evidence: II for act as usualadvice plus self-training and NSAIDS.

Basis for changes to QTF recommendationsLevel II evidence.

The practitioner should reassure the patient by

acknowledging that the patient is hurt and has

symptoms, and advising that:

symptoms are a normal reaction to being hurt,

it is important to focus on improvements in

function, and

maintaining life activities is an important factor

in getting better.



Act as usual should be used as a treatment for

WAD with or without pain relief as per

recommendations regarding pharmacology

see page 28.



Recommended


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27


- prescribed function, work alteration,

acupuncture and relaxation techniques

QTF recommendations for clinical practiceConsensus basis:

WAD Grade I prescribed function, i.e.immediate return to usual activity, isrecommended. Neck school, work alteration,acupuncture and relaxation techniques arenot indicated for Grade I.

WAD Grades II and III prescribed function,i.e. return to usual activity, is encouraged assoon as possible. Neck school, temporary

work alteration, acupuncture and relaxationtechniques are optional adjuncts for symptomduration more than three weeks.

Basis of QTF recommendationsNo additional evidence was found concerningthese treatments.

Additional evidenceNo additional evidence was found regardinguse of these treatments in acute WAD.

One expert reviewer referred to a study ofpatients with minor head injuries (many of

whom have similar problems to whiplashpatients)11 which describes the importance ofgradual return to regular activities. The strategydescribed in the study was individually tailoredand mainly considered the patients effectivelevel of functioning. It showed considerable

advantages in long-term outcome whencompared to arbitrary schemes.

Basis for changes to QTF recommendationsConsensus of the Working Party members wasbased on comments of expert reviewer.

Acupuncture is addressed in separaterecommendation on page 32.


- exercise

QTF recommendations for clinical practiceEvidence based there is insufficient evidenceassessing the independent contribution ofexercise.

Consensus based ROM exercises should beimplemented immediately, in combination ifnecessary with intermittent rest, when pain issevere. Clinical judgment is crucial if symptomsare aggravated.

Basis of QTF recommendationsNo evidence was found regarding independentbenefit of exercise in WAD.

Prescription of home exercise combined withactivation advice, was found to have short- andlong-term benefit for WAD presenting withinfour days of injury.

Additional evidenceNo additional evidence was found regardingindependent benefit of exercise in WAD.

ROM (range of movement) exercises, muscle

re-education and low load isometric exercise to

restore appropriate muscle control and support to the

cervical region, should be implemented immediately, if

necessary in combination with intermittent rest when

pain is severe. Clinical judgment is crucial if

symptoms are aggravated.




Prescribed function, i.e. return to usual activity as

soon as possible, is recommended. Rehabilitation

programs, which may include work alteration andrelaxation techniques, may assist recovery depending

on symptoms (e.g. pain, ability to concentrate) and

psychosocial factors.




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28


- exercise (continued)

A Cochrane Review (1998) on physicalmedicine modalities for management ofmechanical neck disorders concluded there waslack of scientific evidence to determine theefficacy of exercise (Gross AR et al., 1998).

Basis for changes to QTF recommendationsMuscle re-education and low load isometricexercise were added to the QTFrecommendation relating to ROM exercise byconsensus of the Working Party.

Pharmacology

QTF recommendations for clinical practiceConsensus based no medications should beprescribed for WAD Grade I. Non-narcoticanalgesics and NSAIDs can be used to alleviatepain for the short term in WAD Grades II andIII. Their use should not be continued for morethan three weeks, and should be weighedagainst possible side effects. Narcotic analgesicsshould not be prescribed for WAD Grades I andII. Occasionally they may be prescribed for painrelief in acute severe WAD Grade III, but onlyfor a limited period of time. Although commonlyprescribed, muscle relaxants should notgenerally be used in the acute phase of WAD.

The psychopharmacologic drugs are notrecommended for use on a general basis in

WAD of any duration or Grade, but they maybe used occasionally for symptoms such asinsomnia or tension, as an adjunct to activatinginterventions in the acute phase (less than threemonths duration).

For chronic pain in WAD (more than threemonths duration), the minor tranquillisers and

antidepressants may be used.

Basis of QTF recommendationsNo evidence was found regarding the benefit ofnarcotic analgesics or psychopharmacologics in

WAD. No studies were accepted regarding thebenefit of muscle relaxants in WAD.

Analgesics or NSAIDs in combination with othertreatment modalities were found to be of short-term benefit in WAD Grades I and II presenting

within three days of injury (see activation,passive modalities).

Additional evidenceA RCT of WAD Grades I and II givenTenoxicam 20 mg within 72 hours of injury hadbetter ROM and less pain at 15 days comparedto control (Gunzburg R, 1999).

A small RCT of WAD Grades II and III subjectssuggested those treated with high dose 24-hourmethylprednisolone infusion (as per acutespinal cord trauma protocol) had less sick leavecompared to controls (Pettersson K & Toolanen

G, 1998).Rating of additional evidence: II for use ofTenoxicam and for methylprednisilone infusion.

WAD Grade I

No medication other than simple analgesics should beprescribed.

WAD Grades II and IIINon-opioid analgesics and NSAIDs can be used to

alleviate pain for the short term. Their use should be

limited to three weeks and should be weighed

against possible side effects.

Opioid analgesics are not recommended for WAD

Grades I and II. They may be prescribed for pain

relief in acute severe WAD Grade III for a limitedperiod of time.

Muscle relaxants should not generally be used in

acute phase WAD.

Psychopharmacologic drugs are not recommended in

WAD of any duration or grade; however, they may be

used occasionally for symptoms such as insomnia or

tension or as an adjunct to activating interventions

in the acute phase (less than three months duration).

Use of high dose IV methylprednisolone infusion for

acute management of WAD Grades II and III is not

recommended.




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29

Basis for changes to QTF recommendationsWAD Grade I prescription of simpleanalgesics was included by consensus of the

Working Party.

WAD Grades II and III unchanged butreorganised. Working Party preferred the termopioid to narcotic.

Occasionally was deleted for consistency withNHMRC Guidelines for the management of pain.12

The Working Party did not consider the use ofhigh dose IV methylprednisilone infusion, giventhe potential adverse effects, could be justifiedon the basis of a small RCT.

Recommendations regarding thepharmacological management of chronic painare not included as this is outside the scope ofthe guidelines.



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30


Recommended under certain circumstances


- postural advice

QTF recommendations for clinical practiceConsensus based postural advice can be givenin combination with activation in WAD.

Basis of QTF recommendationsNo evidence was found concerning theindependent therapeutic effect of posturalalignment in WAD.

Advice on posture, combined with advice onactivation for WAD presenting within four daysof injury, has short- and long-term benefit.

When combined with physiotherapy, soft collarand analgesics, there was only short-termbenefit.

Additional evidenceNo additional evidence was found concerningthe independent therapeutic effect of posturalalignment in WAD.

In one RCT, Mealy et al., divided subjects intothree groups:

Group 1 = analgesics plus rest;

Group 2 = analgesics plus physical modalities,ROM exercises and mobilisation;

Group 3 = analgesics plus collar plusphysiotherapy advice on mobilisation, postureand ROM exercises.

At two years, Group 3 had fewer symptoms. Attwo years, Group 3 had less pain than Groups 1and 2 (in Hurwitz ET et al., 1996).

Rating of additional evidence: II for the effect ofphysical modalities, ROM exercise, mobilisation;and physiotherapist advice on posture andROM exercise.

Basis for changes to QTF recommendationsRecommendation unchanged other thanreplacing the term activation with manualand physical therapies and exercise.


- mobilisation

QTF recommendations for clinical practiceEvidence based there is weak cumulativeevidence to support their combined use in WAD.

Consensus based a regimen of mobilisationcan be used for WAD.

Basis of QTF recommendationsNo evidence was found concerning theindependent effect of mobilisation on WAD.

Manual mobilisation combined with otherphysiotherapeutic interventions in WADpresenting within four 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 forcombined collar, rest and analgesics.

Postural advice can be given in combination with

manual and physical therapies and exercise in WAD.


Mobilisation can be used for WAD, providing there is

evidence of continuing improvement with the

treatment. If mobilisation is used it should be

commenced early, within the first seven days. This

technique should be restricted to registered health

practitioners trained in the specific methods and

according to current professional standards.




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31

Additional evidenceNo additional evidence was found concerningthe independent effect of mobilisation on WAD.

A major systematic review of manipulation andmobilisation of cervical spine for treatment ofmechanical neck pain and headache publishedin 1996 concluded that these modalities provideshort-term benefit and that more high qualityresearch is required (Hurwitz ET et al., 1996).Three RCTs reviewed found that mobilisationfor acute neck pain provided short-term benefit

(McKinney LA, 1989; McKinney LA et al., 1989;Mealy K et al., 1986).

Mealy K et al., divided subjects into threegroups:

Group 1 = analgesics plus rest;

Group 2 = analgesics plus physical modalities,ROM exercises and mobilisation;

Group 3 = analgesics plus collar plusphysiotherapy advice on mobilisation, postureand ROM exercises.

At two years, Group 3 had fewer symptoms. At

two years, Group 3 had less pain than Groups 1and 2.

Rating of additional evidence: II for short-termbenefit of mobilisation.

Basis for changes to QTF recommendationsLevel II evidence to support short-term benefitof mobilisation for acute neck pain.

- manipulation

QTF recommendations for clinical practiceConsensus based a short-term regime ofmanipulation can be used for WAD. Thistechnique should be restricted to registeredhealth practitioners trained in the specificmethods and according to current professionalstandards.

Basis of QTF recommendationsNo evidence was found addressing the short- orlong-term benefits of a complete course ofmanipulative therapy on WAD.

The immediate effect on pain and ROM of asingle manipulation is similar to that of a singlemobilisation in neck pain of varying duration.There is insufficient evidence assessing theindependent contribution of this technique.

Additional evidenceNo additional evidence was found concerningthe independent effect of manipulation on

WAD.

A major systematic review of manipulation andmobilisation of cervical spine for treatment ofmechanical neck pain and headache publishedin 1996 concluded that these modalities provideshort-term benefit and that more high qualityresearch is required (Hurwitz ET et al., 1996).No RCTs were found examining manipulationfor acute neck pain.

Basis for changes to QTF recommendationsConsensus of Working Party members.

- traction

A regime of manipulation can be used for WAD,

providing there is evidence of continuing improvement

with the treatment. This technique should be

restricted to registered health practitioners trained in

the specific methods and according to current

professional standards. Complications from

manipulation are rare, but include stroke and death.WAD Grade III (decreased or absent deep tendon

reflexes and/or weakness and sensory deficit) is a

relative contra-indication for manipulation.



A regime of traction can be used in combination

with other mobilising modalities in WAD providing

there is evidence of continuing improvement with the

treatment.




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32

- traction (continued)

QTF recommendations for clinical practiceEvidence based there is weak evidence thattraction is of short-term benefit.

Consensus based a regime of traction can beused in combination with other mobilisinginterventions in WAD.

Basis of QTF recommendationsNo evidence was found addressing independenteffects of traction in WAD.

Traction in combination with otherphysiotherapeutic interventions was found to beof short-term benefit in WAD presenting withinfour days of injury, and in neck pain syndromesof indeterminate duration; there was no long-term (two year) benefit for WAD presenting

within four days of injury.

In a small RCT, there were no statisticallysignificant differences between static,intermittent and manual traction in combination

with other physiotherapeutic interventions inneck pain syndromes of indeterminate duration.

Additional evidenceNo additional evidence was found addressingindependent effects of traction in WAD.

A Cochrane Review (1998) on physicalmedicine modalities for mechanical neckdisorders concluded that lack of scientifictesting prevented determination of efficacy oftraction (Gross AR et al., 1998). An earliersystematic review on traction for neck and backpain reported there was no conclusive evidencethat traction was an effective therapy formechanical neck and back pain (Van derHeijden et al., 1995).

Basis for changes to QTF recommendationsGiven the lack of evidence on the effectivenessof traction, by consensus the Working Partyagreed that evidence of improvement inindividual cases would be required to justifyongoing use of traction.

Multimodal



Additional evidenceOne RCT of 60 WAD patients suggestedimproved pain, disability and return to work for

multimodal treatment group compared tocontrol group that received physical modalitiesalone (Provenciali L et al., 1996).

Rating of additional evidence: II for multimodaltreatment.

Basis for changes to QTF recommendationsLevel II evidence to support use of thistreatment. Recommendations regardingappropriate time to commence and the need formonitoring were based on Working Partyconsensus.

A multimodal treatment program can be used for

WAD which has not settled within four to six weeks


with the treatment.




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Acupuncture

QTF recommendations for clinical practice

WAD Grade IAcupuncture is not recommended for WADGrade I (see also page 27 Miscellaneousinterventions).

WAD Grade II and IIIPrescribed function, i.e. return to usual activity,is encouraged as soon as possible, temporary

work alteration, relaxation techniques and

acupuncture are optional adjuncts forsymptom duration greater than three weeks.

Basis of QTF recommendationsOne accepted RCT was found for chronic neckpain (daily neck pain with or without radiationmore than six months). The study suggestedthat acupuncture and NSAIDs or analgesics

were not better than sham TENS with NSAIDsor analgesics for relief of pain.

Additional evidence

No additional evidence was foundindependently examining use of acupuncture inacute WAD.

A Cochrane Review (1998) on use ofacupuncture in neck disorders concluded there

was insufficient quality research to comment oneffectiveness of acupuncture (Gross AR et al.,1998).

Basis for changes to QTF recommendationsGiven the lack of evidence on the effectivenessof acupuncture for WAD, by consensus the

Working Party agreed that acupuncture shouldonly be continued if there was evidence ofimprovement in individual cases.



electrical stimulation, ultrasound,

laser, short-wave diathermy

QTF recommendations for clinical practiceConsensus based:

WAD Grade I: although active PEMT in a softcollar was better than sham PEMT in a softcollar, PEMT is not recommended because itinvolves wearing a soft collar eight hours aday for 12 weeks.

WAD Grades II and III: the other

professionally administered passivemodalities/electrotherapies are optionaladjuncts during the first three weeks toactivating interventions with emphasis onreturn as soon as possible to usual activity.

Basis of QTF recommendationsThere were virtually no accepted studiesaddressing the benefit of these modalities.

Two small RCTs in WAD Grades I and IIpresenting less than 72 hours, and in neck painnot related to WAD more than eight weeksduration, suggest a benefit from PEMTcompared with sham PEMT in pain control

A regime for acupuncture can be used in WAD


with the treatment.



WAD Grade IAlthough active PEMT in a soft collar was better thansham PEMT in a soft collar, PEMT is not

recommended because it involves wearing a soft

collar eight hours a day for 12 weeks.

WAD Grades II and IIIDuring the first three weeks the other professionally

administered passive modalities/electrotherapies are

optional adjuncts to manual and physical therapies

and exercise with emphasis on return to usual

activity as soon as possible.




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34


(continued)

when combined with NSAIDs, activating adviceand soft collar.

All modalities except laser were possible adjunctsto mobilising interventions, which had short-termbenefit equivalent to activation advice.

There were no accepted studies in which thebenefits of laser were addressed.

Additional evidenceNo additional accepted studies independentlyassessing the use of these modalities in acute

WAD Grade I to III were found.

Basis for changes to QTF recommendationsThe only change is the use of the termsmanual and physical therapies and exerciseinstead of activating interventions.

Immobilisation - prescribed rest

QTF recommendations for clinical practiceEvidence based there is weak cumulativeevidence to restrict prescribed rest to shortperiods of time.

Consensus based rest should not beprescribed for WAD Grade I. Rest for more thanfour days should not be prescribed for WADGrades II and III.

Basis of QTF recommendationsNo evidence was found concerningindependent benefit of prescribed rest in WAD.

Prescribed rest for 10 to 14 days in combinationwith soft collars and analgesia in WAD wasassociated with delayed recovery.

Additional evidenceIn a RCT of 201 acute whiplash subjects it wasdemonstrated that an act as usual group hadbetter outcomes in terms of subjectivesymptoms compared to subjects managed with14 days sick leave and immobilisation with softneck collar (Borchgrevink GE, 1998).

Rating of additional evidence: II

Basis for changes to QTF recommendationsRecommendation unchanged.

Comment: the additional evidence referred toabove would suggest that for many cases actas usual should be recommended, andtherefore an additional recommendation hasbeen added to this effect, see page 26.

- collars

QTF recommendations for clinical practiceEvidence based there is weak cumulativeevidence to restrict their use to short periods oftime.

Consensus based collars should not beprescribed for WAD Grade I. If prescribed for

WAD Grades II or III, they should be restrictedto no more than 72 hours.

WAD Grade ICollars should not be prescribed.

WAD Grades II and IIIIf prescribed for WAD Grades II or III, they should

not be used for more than 72 hours.



WAD Grade IRest should not be prescribed for WAD Grade I.

WAD Grades II and IIIRest for more than four days should not be

prescribed for WAD Grades II and III.




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Basis of QTF recommendationsNo evidence was found addressing independentbenefit of collars in WAD.

Soft collars in combination with prescribed restand analgesics are associated with delayedrecovery (pain and ROM) in WAD presenting

within four days of injury.

Soft collars do not restrict ROM in non-injuredsubjects.

Additional evidenceA RCT of 196 acute whiplash subjects indicatedthat use of soft collars did not alter the durationor pain in whiplash patients (Gennis P et al.,1996).

In a RCT of 201 acute whiplash subjects it wasdemonstrated that an act as usual group hadbetter outcomes in terms of subjectivesymptoms compared to subjects managed with14 days sick leave and immobilisation with softneck collar (Borchgrevink GE, 1998). A RCT of220 acute whiplash subjects suggested that

subjects immobilised in collar for four weeksfollowed up by a defined exercise period didbetter than controls and better than a groupmanaged with early defined exercise(Gurumoorthy D, 1999).

Rating of additional evidence: II


Surgical treatment

QTF recommendations for clinical practiceConsensus based There are no indications forsurgical intervention in WAD Grades I and II.Surgery is to be restricted to the rare WADGrade III with persistent arm pain that does notrespond to conservative management or withrapidly progressing neurologic deficit.

Basis of QTF recommendationsNo studies were accepted concerning thebenefit of disc surgery, nerve block or rhizolysis

for any Grade or duration in WAD.

Additional evidenceNo additional accepted study was identifiedregarding the benefits of surgery, nerve blockor rhizolysis in acute management of WADGrades I to III.

Basis for changes to QTF recommendationsThe recommendation has been changed byproviding an example of a case which maybenefit from surgery.

There are no indications for surgical intervention in

almost all cases of WAD Grades I to III. Surgery

should be restricted to the rare WAD Grade III with

persistent arm pain that does not respond to

conservative management or with rapidly progressing

neurological deficit, e.g. cervical radiculopathy

supported by appropriate investigations.




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Immobilisation - cervical pillows

QTF recommendations for clinical practiceConsensus based cervical pillows are notrequired.

Basis of QTF recommendationsNo evidence was found addressing the

therapeutic effects of cervical pillows in WAD.

Additional evidenceNo additional evidence was found.



- spray and stretch

QTF recommendations for clinical practiceConsensus based Spray and stretch is notrecommended.

Basis of QTF recommendationsNo evidence was found concerning theindependent therapeutic effect of spray andstretch in WAD.

Additional evidenceNo additional evidence was found concerningthe independent therapeutic effect of spray andstretch in WAD.


Injections - steroid injections

QTF recommendations for clinical practiceConsensus based intra-articular steroidinjections are not recommended for WAD.Epidural steroid injections are notrecommended for WAD Grades I or II.

Occasionally, WAD Grade III with unresolvedradicular pain of more than one month mightbenefit from epidural steroid injections.


Not recommended

Cervical pillows are not recommended.



Spray and stretch is not recommended.



Intra-articular steroid injection cannot be

recommended for WAD. Epidural steroid injections

should not be used for WAD Grades I or II.

Occasionally, WAD Grade III with unresolved radicular

pain of more than one month might benefit from

epidural steroid injections.

There is no indication for steroid trigger point

injection in the acute phase (less than three 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 isshown in valid RCTs. Intrathecal steroid injections

carry such risk of serious morbidity that they should

be avoided in all grades of WAD.




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There is no indication for steroid trigger pointinjection in the acute phase (less than three

weeks). Because harmful side effects ofrepeated steroid use have been reported,steroid trigger point injections should not beused unless their benefit in WAD is shown in

valid RCTs. Intrathecal steroid injections carrysuch risk of serious morbidity that they shouldbe avoided in all Grades of WAD.

Basis of QTF recommendationsOne accepted study showed no benefit of intra-

articular steroid injections in WAD greater thanthree months.

No accepted studies were found concerning thebenefit of epidural or intrathecal steroidinjections in WAD. No additional evidence wasfound concerning trigger point steroid injectionsin WAD.

Additional evidenceNo accepted studies were found concerning theacute treatment of WAD Grades I to III withepidural or intrathecal steroid injections orconcerning injection of trigger points.



- magnetic necklaces

QTF recommendations for clinical practiceConsensus based magnetic necklaces are notrecommended.

Basis of QTF recommendationsAn accepted RCT indicated that the magneticnecklace is no better than placebo for neckpain of duration greater than one year. No other

evidence was found concerning theeffectiveness of the magnetic necklace.

Additional evidenceNo additional evidence assessing the use ofmagnetic necklaces in treatment of acute WADGrades I to III was identified.


Other interventions e.g. Pilates,

Feldenkrais, Alexander Technique,

massage and homeopathy

QTF recommendations for clinical practiceConsensus based there is no reason for apractitioner to prescribe any of these treatments.

Basis of QTF recommendationsNo evidence was found concerning thesetreatments.

Additional evidenceNo additional evidence independently assessing

use of any of these modalities in acute WADwas identified.

Basis for changes to QTF recommendationsThe wording of the recommendation waschanged for consistency. The Working Partycould not justify recommending any of these inthe treatment of acute WAD.

Magnetic necklaces are not recommended.



Pilates, Feldenkrais, Alexander Technique, massage and

homeopathy are not recommended.




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Injections

- sterile water injections

QTF recommendations for clinical practiceConsensus

Documents

Guidelines for the Management of Whiplash Associated Disorders