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. 2007 Apr 18;2007(2):CD003338.
doi: 10.1002/14651858.CD003338.pub3.

Conservative treatments for whiplash

A P Verhagen  1 , G G G M Scholten-Peeters, S van Wijngaarden, R A de Bie, S M A Bierma-Zeinstra
Affiliations

Conservative treatments for whiplash

A P Verhagen et al. Cochrane Database Syst Rev. .

Abstract

Background: Many treatments are available for whiplash patients but there is little scientific evidence for their accepted use. Patients with whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms from Grade 0 (no complaints or physical signs) to Grade 4 (fracture or dislocation).

Objectives: To assess the effectiveness of conservative treatment for patients with whiplash injuries rated as Grades 1 or 2 (neck and musculoskeletal complaints).

Search strategy: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2006, Issue 3), MEDLINE, CINAHL, PsycINFO, and PEDro to November 2006 and screened references of identified randomised trials and relevant systematic reviews.

Selection criteria: We selected randomised controlled trials published in English, French, German or Dutch, that included patients with a whiplash-injury, conservative interventions, outcomes of pain, global perceived effect or participation in daily activities.

Data collection and analysis: Two authors independently assessed the methodological quality using the Delphi criteria and extracted the data onto standardised data-extraction forms. We did not pool the results because of the heterogeneity of the population, intervention and outcomes and lack of data. A pre-planned stratified analysis was performed for three different comparisons.

Main results: Twenty-three studies (2344 participants) were included in this update, including nine new studies. A broad variety of conservative interventions were evaluated. Two studies included patients with chronic symptoms (longer than three months), two included subacute (four to six weeks) symptoms, two had undefined duration of symptoms, and 17 studied patients with acute (less than three weeks) symptoms. Only eight studies (33.3%) satisfied one of our criteria of high quality, indicating overall, a poor methodological quality. Interventions were divided into passive (such as rest, immobilisation, ultrasound, etc) and active interventions (such as exercises, act as usual approach, etc.) and were compared with no treatment, a placebo or each other. Clinical and statistical heterogeneity and lack of data precluded pooling. Individual studies demonstrated effectiveness of one treatment over another, but the comparisons were varied and results inconsistent. Therefore, the evidence neither supports nor refutes the effectiveness of either passive or active treatments to relieve the symptoms of WAD, Grades 1 or 2.

Authors' conclusions: The current literature is of poor methodological quality and is insufficiently homogeneous to allow the pooling of results. Therefore, clearly effective treatments are not supported at this time for the treatment of acute, subacute or chronic symptoms of whiplash-associated disorders.

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Conflict of interest statement

None

Figures

1.1
1.1. Analysis
Comparison 1 Passive intervention versus placebo, Outcome 1 Improvement.
2.1
2.1. Analysis
Comparison 2 Passive intervention versus no treatment, Outcome 1 Pain.
2.2
2.2. Analysis
Comparison 2 Passive intervention versus no treatment, Outcome 2 Recovery.
3.1
3.1. Analysis
Comparison 3 Active intervention (e.g. physiotherapy) versus no treatment, Outcome 1 Neck pain.
3.2
3.2. Analysis
Comparison 3 Active intervention (e.g. physiotherapy) versus no treatment, Outcome 2 Headaches.
4.1
4.1. Analysis
Comparison 4 Active intervention (e.g. physiotherapy) versus passive intervention (e.g. collar, rest), Outcome 1 Neck pain.
4.2
4.2. Analysis
Comparison 4 Active intervention (e.g. physiotherapy) versus passive intervention (e.g. collar, rest), Outcome 2 Neck pain.
4.3
4.3. Analysis
Comparison 4 Active intervention (e.g. physiotherapy) versus passive intervention (e.g. collar, rest), Outcome 3 Range of motion.
4.4
4.4. Analysis
Comparison 4 Active intervention (e.g. physiotherapy) versus passive intervention (e.g. collar, rest), Outcome 4 Return to work.
4.5
4.5. Analysis
Comparison 4 Active intervention (e.g. physiotherapy) versus passive intervention (e.g. collar, rest), Outcome 5 Return to work.
4.6
4.6. Analysis
Comparison 4 Active intervention (e.g. physiotherapy) versus passive intervention (e.g. collar, rest), Outcome 6 Global improvement.
5.1
5.1. Analysis
Comparison 5 Active intervention versus active intervention, Outcome 1 Recovery.
5.2
5.2. Analysis
Comparison 5 Active intervention versus active intervention, Outcome 2 Pain.
5.3
5.3. Analysis
Comparison 5 Active intervention versus active intervention, Outcome 3 Pain.
5.4
5.4. Analysis
Comparison 5 Active intervention versus active intervention, Outcome 4 Work activities.
6.1
6.1. Analysis
Comparison 6 Additional exercises in acute patients, Outcome 1 Pain.
6.2
6.2. Analysis
Comparison 6 Additional exercises in acute patients, Outcome 2 Range of motion.
7.1
7.1. Analysis
Comparison 7 Additional exercises in chronic patients, Outcome 1 Disability.
7.2
7.2. Analysis
Comparison 7 Additional exercises in chronic patients, Outcome 2 Pain.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Aigne 2006 {published data only}
    1. Aigner N, Fialka C, Radda C, Vecsei V. Adjuvant laser acupuncture in the treatment of whiplash injuries: a prospective randomised placebo‐controlled trial. Wiener Klinische Wochenschrift 2006;118:95‐9. - PubMed
Bonk 2000 {published data only}
    1. Bonk AD, Ferrari R, Giebel GD, Edelmann M, Huser R. Prospective, randomized, controlled study of activity versus collar, and the natural history for whiplash injury, in Germany. Journal of Musculoskeletal Pain 2000;8(1/2):123‐32.
    1. Giebel GD, Edelmann M, Hüser R. Neck sprain: physiotherapy versus collar treatment [Die Distorsion der Halswirbelsaule: frühfunctionalle versus ruhigstellende Behandlung]. Zentralblatt für Chirurgie 1997;122:517‐21. - PubMed
Borchgrevink 1998 {published data only}
    1. Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I. Acute treatment of whiplash neck sprain injuries. A randomized trial of treatment during the first 14 days after a car accident. Spine 1998;23(1):25‐31. - PubMed
Brison 2005 {published data only}
    1. Brison RJ, Hartling L, Dostaler S, Leger A, Rowe BH, Stiell I, et al. A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear‐end motor vehicle collisions. Spine 2005;30:1799‐1807. - PubMed
Bunketorp 2006 {published data only}
    1. Bunketorp L, Lindh M, Carlsson J, Stener‐Victorin E. The effectiveness of a supervised physical training model tailored to the individual needs of patients with whiplash‐associated disorders; a randomized controlled trial. Clinical Rehabilitation 2006;20:201‐17. - PubMed
Crawford 2004 {published data only}
    1. Crawford JR, Khan RJK, Varley GW. Early management and outcome following soft tissue injuries of the neck‐a randomized controlled trial. Injury, Int. J. Care Injured 2004;35:891‐5. - PubMed
Ferrari 2005 {published data only}
    1. Ferrari R, Rowe BH, Majumdat SR, Cassidy JD, Blitz S, Wright SC, et al. Simple educational intervention to improve the recovery from acute whiplash: results of a randomised, controlled trial. Academic Emergency Medicine 2005;12:699‐706. - PubMed
Fialka 1989 {published data only}
    1. Fialka V, Preisinger E, Böhler A. Zur physikalischen diagnostik und physikalischer therapie der distorsio columnae vertebralis cervicalis. Z Phys Med Baln Med Klim 1989;18:390‐7.
Fitz‐Ritson 1995 {published data only}
    1. Fitz‐Ritson D. Phasic exercises for cervical rehabilitation after 'whiplash' trauma. J Manipulative Physiol Ther 1995;18(1):21‐4. - PubMed
Florio 1999 {published data only}
    1. Florio A, Ceruti R, Sguazzini‐Viscontini G, Cisari C. The sequelae of cervical whiplash injury. Static posturography for evaluating disability and the efficacy of rehabilitation (mesotherapy versus physiotherapy). Europa Medicophysica 1999;35:171‐6.
Foley‐Nolan 1992 {published data only}
    1. Foley‐Nolan D, Moore K, Codd M, Barry C, O'Conner P, Coughlan RJ. Low energy high frequency pulsed electromagnetic therapy for acute whiplash injuries: a double blind randomized controlled study. Scand J Rehab Med 1992;24(1):51‐9. - PubMed
Hendriks 1996 {published data only}
    1. Hendriks O, Horgan A. Ultra‐reiz current as an adjunct to standard physiotherapy treatment of the acute whiplash patient. Physiotherapy Ireland 1996;17(1):3‐7.
McKinney 1989 {published data only}
    1. McKinney LA. Early mobilisation and outcome in acute sprains of the neck. BMJ 1989;299:1006‐8. - PMC - PubMed
    1. McKinney LA, Dornan JO, Ryan M. The role of physiotherapy in the management of acute neck sprains following road traffic accidents. Archives of Emergency Medicine 1989;6:27‐33. - PMC - PubMed
Mealy 1986 {published data only}
    1. Mealy K, Brennan H, Fenelon GCC. Early mobilisation of acute whiplash injuries. BMJ 1986;292(8):656‐7. - PMC - PubMed
Oliveira 2006 {published data only}
    1. Oliveira A, Gevirtz R, Hubbard D. A psycho‐educational video used in the emergency department provides effective treatment for whiplash injuries. Spine 2006;31:1652‐7. - PubMed
Pennie 1990 {published data only}
    1. Pennie BH, Agambar LJ. Whiplash injuries: a trial of early management. J Bone Joint Surg 1990;72(2):277‐9. - PubMed
Provinciali 1996 {published data only}
    1. Provinciali L, Baroni M, Illuminati L, Ceravolo MG. Multimodal treatment to prevent the late whiplash syndrome. Scan J Rehab Med 1996;28:105‐11. - PubMed
Rosenfeld 2000 {published data only}
    1. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash‐associated disorders. Spine 2000;25:1782‐1787. - PubMed
    1. Rosenfeld M, Seferiadis A, Carlsson J, Gunnarsson R. Active intervention in patients with whiplash‐associated disorders improves long‐term prognosis. Spine 2003;28(20):2491‐2498. - PubMed
    1. Rosenfeld M, Seferiadis A, Gunnarsson R. Active involvement and intervention in patients exposed to whiplash trauma in automobile crashes reduces costs. Spine 2006;31(16):1799‐1804. - PubMed
Schnabel 2004 {published data only}
    1. Schnabel M, Ferrari R, Vassiliou T, Kaluza G. Randomised controlled outcome study of active mobilization compared with collar therapy for whiplash injury. Emerg Med Journal 2004;21:306‐10. - PMC - PubMed
    1. Schnabel M, Vassiliou T, Schmidt T, Basler HD, Gotzen L, Junge A, et al. Results of early mobilisation of acute whiplash injuries. Schmerz 2002;16:15‐21. - PubMed
    1. Vassiliou T, Kaluza G, Putzke C, Wulf H, Schnabel M. Physical therapy and active exercises; an adequate treatment for prevention of late whiplash syndome? A randomised controlled trial in 200 patients. Pain 2006;124:69‐76. - PubMed
Scholten‐Peeters2006 {published data only}
    1. Scholten‐Peeters GGM, Neeleman‐van der Steen CWN, Windt DAWM, Hendriks EJM, Verhagen AP, Oostendorp RAB. Education by general practitioners or education and exercises by physiotherapists for patients with whiplash‐associated disorders? A randomized clinical trial. Spine 2006;31:723‐31. - PubMed
Söderlund 2000 {published data only}
    1. Söderlund A, Olerud C, Lindberg P. Acute whiplash‐associated disorders (WAD): the effects of early mobilization and prognostic factors in long‐term symptomatology. Clinical Rehabilitation 2000;14:457‐67. - PubMed
Söderlund 2001a {published data only}
    1. Söderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD); A randomised group study. Physiotherapy Theory and Practice 2001;17:229‐38. - PubMed
Thuile 2002 {published data only}
    1. Thuile Ch, Walzl M. Evaluation of electromagnetic fields in the treatment of pain in patients with lumbar radiculopathy or the whiplash syndrome. NeuroRehabilitation 2002;17:63‐7. - PubMed

References to studies excluded from this review

Corey 1996 {published data only}
    1. Corey DT, Koepfler LE, Etlin D, Day HI. A limited functional restoration program for injured workers: A randomised trial. J Occup Rehabil 1996;6(4):239‐49. - PubMed
Fockler 1998 {published data only}
    1. Fockler SKF, Vavrik J, Kristiansen L. Motivating drivers to correctly adjust head restraints: Assessing effectiveness of three different interventions. Accident Analysis and Prevention 1998;30(6):773‐80. - PubMed
Gennis 1996 {published data only}
    1. Gennis P, Miller L, Gallagher EJ, Giglio J, Nathanson N. The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med 1996;3(6):568‐73. - PubMed
Goodman 2000 {published data only}
    1. Goodman R, Frew LJ. Effectiveness of progressive strength resistance training for whiplash: A pilot study. Physiotherapy Canada 2000;Summer:211‐4.
Sterner 2001 {published data only}
    1. Sterner Y, Löfgren M, Nyberg V, Karlson AK, Bergström M, Gerdle B. Early interdisciplinary rehabilitation programm for whiplash assocated disorders. Disability and Rehabilitation 2001;23(10):422‐9. - PubMed
Suissa 2006 {published data only}
    1. Suissa S, Giroux M, Gervais M, Proulx P, Desbiens C, Delany J, et al. Assessing a whiplash management model: A population‐based non‐randomised intervention study. Journal of Rheumatology 2006;33:581‐7. - PubMed
Söderlund 2001b {published data only}
    1. Söderlund A, Lindberg P. An integrated physiotherapy/cognitive behavioural approach to the analysis and treatment of chronic whiplash associated disorders: WAD. Disability and Rehabilitation 2001;23(10):436‐47. - PubMed
Zapletal 1999 {published data only}
    1. Zapletal J, Duijn MA. Mechanical efficacy of the mobilising cervical support device (Mbrace). Prosthetics and Orthotics International 1999;23:274‐7. - PubMed

Additional references

Aker 1996
    1. Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta‐analysis. BMJ 1996;313:1291‐6. - PMC - PubMed
Barnsley 1994
    1. Barnsley L, Lord S, Bogduk N. Whiplash injury: clinical review. Pain 1994;58(3):283‐307. - PubMed
Bogduk 1986
    1. Bogduk N. The anatomy and pathophysiology of whiplash: Review paper. Clin Biomech 1986;1(2):92‐101. - PubMed
Cassidy 2000
    1. Cassidy JD, Caroll LJ, Coté P, Lemstra M, Berglund A, Nygren A. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. New England Journal of Medicine 2000;342:1179‐86. - PubMed
Coté 2001
    1. Coté P, Cassidy JD, Carroll L, Frank JW, Bombardier C. A systematic review of the prognosis of acute whiplash and a new conceptual framework to synthesize the literature. Spine 2001;26:E445‐58. - PubMed
Dickersin 1987
    1. Dickersin K, Chan S, Chalmers TC, Sacks HS, Smith Jr H. Publication bias and clinical trials. Contr Clin Trials 1987;8:343‐53. - PubMed
Freeman 1998
    1. Freeman MD, Croft AC, Rossignol AM. "Whiplash Associated Disorders: Redefining whiplash and Its management" by the Quebec Task Force: A Critical Evaluation. Spine 1998;23(9):1043‐9. - PubMed
Hildingsson 1990
    1. Hildingsson C, Toolanen G. Outcome after soft‐tissue injury of the cervical spine. A prospective study of 93 car‐accident victims. Acta Orthop Scand 1990;61:357‐9. - PubMed
Jadad 1998
    1. Jadad AR, Moher D, Klassen TP. Guides for reading and interpreting systematic reviews: II How did the authors find the studies and assess their quality?. Arch Pediatr Adolesc Med 1998;152:812‐7. - PubMed
Kasch 2000
    1. Kasch H, Flemming WB, Jensen TS. Handicap after acute whiplash injury. A 1‐year prospective study of risk factors. Neurology 2000;56:1637‐43. - PubMed
Landis 1977
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159‐74. - PubMed
Miles 1988
    1. Miles KA, Maimaris C, Finlay D, Barnes MR. The incidence and prognostic significance of radiological abnormalities in soft tissue injuries to the cervical spine. Skeletal Radiol 1988;17:493‐6. - PubMed
Moher 1996
    1. Moher D, Jadad AR, Tugwell P. Assessing the quality of randomized controlled trials: Current issues and future directions. Int J Technol Assess Health Care 1996;12:196‐208. - PubMed
Moher 1999
    1. Moher D, Chalmers TC, Cook DJ, Eastwood S, Olkin I, Rennie D, et al. Improving the quality of reports of meta‐analyses of randomized controlled trials: the QUORUM statement. Lancet Eprint 1999;99ART/4149:UR. - PubMed
Norris 1983
    1. Norris SH, Watt I. The prognosis of neck injuries resulting from rear‐end vehicle collisions. J Bone Joint Surg 1983;Br Vol 65B(5):608‐11. - PubMed
Philadelphia 2001
    1. Philadelphia Panel. Philadelphia panel evidence‐based clinical practice guidelines on selected rehabilitation interventions for neck pain. Physical Therapy 2001;81(10):1701‐17. - PubMed
Radanov 1991
    1. Radanov BP, Stefano G, Schnidrig A, Ballinari P. Role of psychosocial stress in recovery from common whiplash. Lancet 1991;338:712‐5. - PubMed
Scholten‐Peeters 2003
    1. Scholten‐Peeters GGM, Verhagen AP, Bekkering GE, Windt DAWM, Barnsley L, Oostendorp RAB, et al. Prognostic factors of whiplash‐associated disorders: A systematic review of prospective cohort studies. Pain 2003;104:303‐22. - PubMed
Schulz 1995
    1. Schulz KF, Chalmers I, Hayes RJ, Altman D. Empirical evidence of bias‐dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408‐12. - PubMed
Seferiadis 2004
    1. Seferiadis A, Rosenfeld M, Gunnarsson R. A review of treatment interventions in whiplash associated disorders. European Spine Journal 2004;13(5):387‐97. - PMC - PubMed
Smidt 2002
    1. Smidt N, Assendelft WJ, Windt DA, Hay EM, Buchbinder R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23‐40. - PubMed
Spitzer 1995
    1. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec Task Force on Whiplash Associated Disorders: Redefining 'whiplash' and it's management. Spine 1995;20(8S):8S‐58S. - PubMed
Stovner 1996
    1. Stovner LJ. The nosologic status of the whiplash syndrome: a critical review based on a methodological approach. Spine 1996;21(23):2735‐46. - PubMed
Söderlund 1999
    1. Söderlund A, Lindberg P. Long‐term functional and psychological problems in whiplash associated disorders. Int J Rehabil Res 1999;22:77‐84. - PubMed
van Tulder 2003
    1. Tulder M, Furlan A, Bombardier C, Bouter L, Editorial Board of the Cochrane Collaboration Back Review Group. Updated method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group. Spine 2003;28(12):1290‐9. - PubMed
Verhagen 1998
    1. Verhagen AP, Vet HCW, Bie RA, Kessels AGH, Boers M, Bouter LM, et al. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998;51:1235‐41. - PubMed
Verhagen 1998b
    1. Verhagen AP, Vet HCW, Bie RA, Kessels AGH, Boers M, Knipschild PG. Balneotherapy and quality assessment: the interobserver reliability of the Maastricht criteria list and the need of blinded quality assessment. J Clin Epid 1998;51:335‐41. - PubMed
Verhagen 2000
    1. Verhagen AP, Bie RA, Lenssen AF, Vet HCW, Kessels AGH, Boers M, et al. Quality assessment of trials: a comparison of three criteria lists. Physical Therapy Reviews 2000;5:49‐58.
Verhagen 2001
    1. Verhagen AP, Vet HCW, Bie RA, Boers M, Brandt PA. The art of quality assessment of RCTs included in systematic reviews. Journal of Clinical Epidemiology 2001;54:651‐4. - PubMed
Waddell 1998
    1. Waddell G, Nachemson AL, Phillips RB. The Back Pain Revolution. London: Churchill Livingstone, 1998:223‐240.
Windt 1995
    1. Windt van der DAWM, Heijden van der GJMG, Scholten RJPM, Koes BW, Bouter LM. The efficacy of non‐steroidal anti‐inflammatory drugs (NSAIDS) for shoulder complaints. A systematic review. J Clin Epidemiol 1995;48:691‐704. - PubMed
Wismans 1994
    1. Wismans KSHM, Huijkens CG. Incidentie en prevalentie van het ‘whiplash’‐trauma. TNO report 94. R.B.V.041. Delft: TNO Road‐Vehicle Research Institute, 1994.

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