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Guidelines for the Management ofWhiplash-Associated Disorders Manual and physical therapies Flow chart of guidelines Notes to accompany flow chart Recommended under certain
Summary of recommendations
for clinical practice
Manual and physical therapies - postural advice Purpose of the guidelines
Definition of condition and scope of the guidelines Passive modalities/electrotherapies - heat, ice, massage, TENS, PEMT, electrical stimulation, ultrasound, laser, short-wave diathermy for clinical practice
Immobilisation - prescribed rest, collars 34
Diagnosis 18
Surgical treatment Physical examination Immobilisation - cervical pillows Plain radiographs Manual and physical therapies Specialised imaging techniques - spray and stretch Specialised examinations Injections - steroid injections Prognosis
Miscellaneous interventions - magnetic necklaces Radiological findings Other interventions Psychosocial factors - e.g. Pilates, Feldenkrais, Alexander Technique, massage, homeopathy Not relevant to treatment of acute
Treatment
WAD Grades I, II or III
Injections - sterile water injections, local anaesthetic or nerve blocks The Working Party
Miscellaneous interventions - prescribed function, work alteration, acupuncture and relaxation techniques Guidelines for the Management ofWhiplash-Associated Disorders There is potentially great benefit in agreeing on effective ways to manage acuteWhiplash-Associated Disorders. Consequently, the MAA decided to take on the taskof developing guidelines for the management of Whiplash-Associated Disorders.
In October 1999 new legislation was enacted to deliver more comprehensively evidence- governing the operations of the New South based recommendations for the management of Wales Motor Accidents Authority (MAA) and the this condition in the future.
Compulsory Third Party (CTP) insurance The Quebec Task Force on Whiplash-Associated scheme it administers.
Disorders1 was convened as a result of the One aim of the legislative change under the Quebec Automobile Insurance Society request Motor Accidents Compensation Act 1999 is to for an "in-depth analysis of clinical, public improve the capacity of the scheme to ensure health, social and financial determinants of the that "reasonable and necessary" care is whiplash problem". The QTF focused on delivered to people with injuries and illness clinical issues, specifically risk, diagnosis, following motor vehicle accidents. treatment and prognosis of whiplash. Duringdevelopment of the guidelines, the QTF Changes made to the scheme are intended to reviewed 10,000 publications. In addition, a improve the quality of medical assessments and cohort of whiplash subjects from the injury ensure that care provided is consistent with the claim files of the Quebec Automobile Insurance best available knowledge of appropriate and Society was identified and prognostic factors in effective diagnosis, treatment, rehabilitation and the recovery process were examined. The QTF ongoing support.
released its findings in a scientific monograph The legislation introduces these changes: • New procedures for resolving disputes about In general, the available evidence was found medical and rehabilitation issues, where to be sparse and of poor quality. While the possible based on the principles of QTF would have preferred to base the recommendations on research findings, it was • Medical assessors from a range of health necessary to develop the guidelines largely on backgrounds to resolve ‘medical' disputes.
consensus and the expert knowledge of • New guidelines for the assessment of members of the QTF who were drawn from many clinical fields. Despite uncovering somenew evidence, the same problem has faced the • New guidelines for the appropriate treatment, Working Party preparing these guidelines five rehabilitation and care of injured persons.
years later.
Whiplash-Associated Disorders (WAD) is the In these guidelines, changes to the single most frequently recorded injury amongst recommendations of the QTF have been based CTP claimants in NSW. It was a factor in 38.9% on available new evidence published since the of claims and responsible for 25% of costs in QTF literature review. Where published evidence is lacking or inconsistent, a consensus As an interim measure, the MAA accepted a of the Working Party (i.e. majority view of all proposal to update the Quebec Task Force members) is given. When making its (QTF) guidelines. This method offered a recommendations, the Working Party also took practical, cost-effective and immediate way to into account comment received during a move ahead on the issue. Looking ahead, the broader consultation and reviews by three National Musculoskeletal Initiative is expected 1 See Notes, page 43 The MAA is aware that the work of the QTF has review of the world literature on whiplash" been criticised,2 with major criticisms being: which "established the baseline scientific • the work is largely consensus based rather knowledge in this subject area and created the than evidence based (due to lack of first evidence-based patient care guidelines".3 Clinical utility has been uppermost in the minds • selection criteria for the literature review were of the team working on this project. The MAA not clear and some evidence, which indicated hopes that the guidelines will be useful to that studies demonstrating WAD to be other primary care practitioners, consumers and the than a self-limiting condition of temporary insurance industry. discomfort and no permanent harm, was These guidelines are to cover the first 12 weeks excluded (i.e. selection bias). following the motor vehicle accident.
The criticism of a bias towards viewing WAD as Of course, these guidelines only offer a starting a self-limiting condition was noted and does not point. It is important to encourage practitioners affect the recommendations on diagnosis and to consult the guidelines and to ask for their treatment which form the substance of these feedback. Rather than perfecting the guidelines guidelines. The guidelines recognise that the in theory, the MAA has planned a strategy to natural course of the condition can go beyond publish, distribute and test these guidelines in the acute phase addressed here.
New South Wales. While acknowledging these criticisms, the MAAaccepted that other experts in this area view theQTF guidelines as "the first ever systematic 2, 3 See Notes, page 43 Guidelines for early management of Whiplash-Associated Disorders Physical examination neck complaint and neck complaint and neck complaint and suspected musculoskeletal signs neurological signs fracture or dislocation X-ray as in guidelines, rarely for WAD Grades I and II, routine for Grades III and IV.
Positive for fracture/dislocation.
Reassure, encourage activity.
Immediate referral to Manage pain.
A&E or specialist surgeon.
Return to usual activity.
Manage pain, explain/reassure, encourage activity.
If Grade III consider short-term rest, collar and ice.
If not resolving, reassess Reassurance and encouragement to return to usual activities.
and consider manual and If not resolving, reassess and consider manual and physical therapies.
physical therapies.
If not resolving, seek If not resolving, reassess.
Specialist advice*.
If not resolving, If not resolving, seek Specialist advice*.
multi-disciplinary pain team or rehabilitation If not resolving, multi-disciplinary pain team or rehabilitation provider evaluation.
*Specialist advice – consultation with a health professional with specialist expertise in managing WAD.
‘Resolving' – refers to both functional and symptomatic improvement.
More initial subjective complaints and concernregarding long-term prognosis If one or more of the following adverse prognosticindicators are present, more intensive treatment Multiple initial symptoms and/or earlier referral may be required.
Severity of neck symptoms and radicularirritation Presence of specific symptoms such as headache; Not in full-time employment muscle pain; pain or numbness radiating from Having dependants neck to arms, hands or shoulders Presence of osteoarthritis on X-ray Notes to accompany flow chart
These are guidelines only.
potential for more intensive treatment and/orreferral should be considered. There will be individual variations.
GPs should reassess patients regularly, at least An ever-present problem in managing at the intervals on the flow chart.
Whiplash-Associated Disorders as recommendedin this flow chart is possible delay between the Consultations should include an assessment as time of requesting an appointment with a to whether patients are gaining improvement specialist, multi-disciplinary pain or from therapy programs, including those being rehabilitation team and the subsequent date of delivered elsewhere, e.g. physical or manual the appointment. One solution, especially for therapy. If improvement is not evident, GPs cases with adverse prognostic indicators (yellow should consider liaising with the therapist or flags), would be to make a provisional curtailing that treatment.
appointment before the need is urgent. GPs and Usually, referral for physical therapy or manual specialists could negotiate an arrangement that therapy is not required for the first few days, enables the appointment to be cancelled if not but if required, should commence within seven These guidelines cover the management of Whole person treatment includes managing any WAD Grades I to III in the acute and sub-acute accompanying anxiety and/or depression that phases, up to around three months from injury.
may be associated with WAD or with other The exit points from here are indicated in the stressful life events.
flow chart by a dark blue box. These are: • referral to a multi-disciplinary pain team or WAD Grade I has been considered separately rehabilitation provider for WAD Grade I for a from WAD Grades II and III as more expedient case which is not resolving after six weeks resolution is expected. Also, referral isrecommended earlier for unresolving cases, • referral to a multi-disciplinary pain team or especially if psychosocial factors appear to be rehabilitation provider for WAD Grades II delaying recovery.
and III for a case which is not resolving at 12 weeks If the patient presents with any known adverse • referral to A&E or a specialist surgeon for prognostic indicators (yellow flags), the WAD Grade IV.
4 See Notes, page 43 Summary of recommendations 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.
Diagnosis of Whiplash-Associated Disorders History taking is important during all visits for A focused physical examination is necessary the treatment of WAD patients of all grades.
for all patient visits. The physical examinationshould include at least: The history should include information about: • date of birth, gender, occupation, number of dependants, marital status • palpation for tender points • prior history of neck problems including • ROM in flexion-extension, rotation and lateral previous whiplash injury • prior history of psychological disturbance • neurological examination to assess sensorimotor function and tendon reflexes of • prior history of long-term problems in upper and lower limbs adjusting to symptoms of an injury or illness • assessment of associated injuries • current psychosocial problems, e.g. family, job-related, financial problems • assessment of general medical condition as needed, including mood, affect and • symptoms including pain, stiffness, numbness, weakness and associated extracervicalsymptoms – localisation, time of onset and A universal goniometer can be used to measure profile of onset should be recorded for all neck ROM, and/or a hand-held dynamometer can be used to measure strength.
• circumstances of injury (sport, motor Both positive and negative findings should be vehicle…); mechanism of injury, e.g. if the recorded. A standardised form may be used. 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 WAD Grade I patients do not require a plain • results of assessments conducted using tools radiograph on presentation if they: to measure general psychological state andpain and disability outcomes, e.g., the • are conscious General Health Questionnaire (GHQ), a visual • show no signs of alcohol-related impairment analogue pain scale or a neck disability • are not obtunded by narcotics or other drugs index – examples of these are available from • show no physical signs on examination, have not been involved in a high speed or high History details should be recorded. A standard impact injury, or in a collision where another form may be used.
occupant has been killed. Specialised imaging techniques
In patients presenting as WAD Grade II, plainX-rays of the cervical spine should be taken if: WAD Grades I and II • the severity of the signs on examination There is no role for specialised imaging suggest the possibility of a bony injury techniques (e.g. tomography, CAT scan, MRI, • their level of consciousness or pain sensation myelography, discography etc.) in WAD Grades is impaired by brain injury or alcohol or other • they have been involved in high speed or Specialised imaging techniques might be used high impact injury, or in a collision where in selected WAD Grade III patients, e.g. nerve another occupant has been killed. root compression or suspected spinal cord Flexion and extension views may occasionally injury, on the advice of a medical or surgical be indicated.
All patients who present with WAD Grade IIIshould have baseline radiological investigation Specialised examinations were considered by of the cervical spine including anterior- the Working Party as not relevant to posterior, lateral and open-mouthed views. All management of WAD Grades I to III. Examples seven cervical vertebral and the C7-T1 disc include EEG, EMG and specialised peripheral should be well visualised. Flexion-extension neural tests.
views may occasionally be indicated.
Summary of recommendations (continued) Prognosis of Whiplash-Associated Disorders Poor outcome has been associated with: Poor outcome may be associated with: • severity of neck symptoms and radicular • prior history of psychological disturbance – irritation at initial assessment these disturbances may be indicative of a • presence of specific symptoms such as proneness to emotional/affective problems headache; muscle pain; pain or numbness and somatisation reactions, which are radiating from neck to arms, hands or frequently based on affective disorders; somatisation reaction in the course of WADmay establish a basis for symptom • history of pre-traumatic headaches augmentation; without early identification and • previous history of head injury proper treatment, this condition may lead to • initial injury reaction (sleep disturbance, • prior history of long-term problems in • more initial subjective complaints and adjusting to symptoms of an injury or illness, concern regarding long-term prognosis e.g. coping mechanisms • pre-existing osteoarthritis • current psychosocial problems, e.g. family, • head rotated or inclined at time of impact; job-related, financial problems.
occupancy in truck/bus; being in head-on or These yellow flag factors should alert the practitioner to the potential need for more intensive treatment or earlier referral.
Identification of these yellow flag factors should alert thepractitioner to the potential need for more intensive treatment or earlier referral.
In addition to the fact that management of this condition, by definition, is taking place in thecontext of compensation (recognised as an Poor outcome may be associated with pre- adverse prognostic indicator), other socio- existing osteoarthritis on the initial cervical demographic indicators associated with poor This yellow flag factor should alert the practitioner to thepotential need for more intensive treatment or earlier referral.
• female gender • not in full-time employment • having dependants. These yellow flag factors should alert the practitioner to thepotential need for more intensive treatment or earlier referral.
Treatment of Whiplash-Associated Disorders Manual and physical therapies
- exercise
The practitioner should reassure the patient –by acknowledging that the patient is hurt and ROM exercises, muscle re-education and low has symptoms, and advising that: load isometric exercise to restore appropriate • symptoms are a normal reaction to being hurt muscle control and support to the cervical • it is important to focus on improvements in region should be implemented immediately, if necessary in combination with intermittent restwhen pain is severe. Clinical judgment is crucial • maintaining life activities is an important if symptoms are aggravated. factor in getting better.
Act as usual
Act as usual – should be used as a treatment for WAD with or without pain relief as per No medication should be prescribed other than recommendations regarding pharmacology.
simple analgesics. Miscellaneous interventions -
WAD Grades II and III prescribed function, work alteration
Non-opioid analgesics and NSAIDs can be used and relaxation techniques
to alleviate pain for the short term. Their useshould be limited to three weeks and weighed Prescribed function, i.e. return to usual activity against possible side effects.
as soon as possible, is recommended.
Opioid analgesics are not recommended for Rehabilitation programs which may include WAD Grades I and II. They may be prescribed work alteration and relaxation techniques, may for pain relief in acute severe WAD Grade III assist recovery depending on symptoms (e.g.
for a limited period of time.
pain, ability to concentrate) and psychosocialfactors.
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.
Summary of recommendations (continued) Recommended under certain circumstances Manual and physical therapies
- postural advice
A regime for acupuncture can be used in WAD Postural advice can be given in combination providing there is evidence of continuing with manual and physical therapies and improvement with the treatment.
exercise in WAD.
Passive modalities/electrotherapies
- heat, ice, massage, TENS, PEMT,
electrical stimulation, ultrasound, laser,
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 first seven days. This technique should be restricted Although active PEMT in a soft collar is better to registered health practitioners5 trained in the than sham PEMT in a soft collar, PEMT is not specific methods and according to current recommended because it involves wearing a soft collar eight hours/day for 12 weeks.
WAD Grades II and III During the first three weeks, other A regime of manipulation can be used for WAD, professionally administered passive providing there is evidence of continuing modalities/electrotherapies are optional adjuncts improvement with the treatment. This technique to manual and physical therapies and exercise.
should be restricted to registered health Emphasis should be placed on return to usual practitioners trained in the specific methods and activity as soon as possible.
according to current professional standards.5Complications from manipulation are rare, but Immobilisation - prescribed rest
include stroke and death. WAD Grade III(decreased or absent deep tendon reflexesand/or weakness and sensory deficit) is a relative contra-indication for manipulation.
Rest is not recommended for WAD Grade I.
- traction
WAD Grades II and IIIRest for more than four days is not A regime of traction can be used in recommended for WAD Grades II and III.
combination with other mobilising modalities inWAD providing there is evidence of continuing Immobilisation - collars
improvement with the treatment.
WAD Grade I Collars are not recommended for WAD Grade I.
A multimodal treatment program can be usedfor WAD that has not settled within four to six WAD Grades II and III weeks providing there is evidence of continuing If prescribed for WAD Grade II or III, they improvement with the treatment.
should not be used for more than 72 hours.
5 See Notes, page 43 WAD Grade III with persistent arm pain thatdoes not respond to conservative management, There are no indications for surgical or with rapidly progressing neurological deficit, intervention in almost all cases of WAD Grades e.g. cervical radiculopathy supported by I to III. Surgery should be restricted to the rare Immobilisation - cervical pillows
repeated steroid use have been reported,steroid trigger point injections should not be Cervical pillows are not recommended. used unless their benefit in WAD is shown invalid RCTs. Intrathecal steroid injections carry Manual and physical therapies -
such risk of serious morbidity that they should spray and stretch
be avoided in all grades of WAD.
Spray and stretch is not recommended.
Miscellaneous interventions
- magnetic necklaces
Injections - steroid injections
Magnetic necklaces are not recommended.
Intra-articular steroid injections can not berecommended for WAD. Epidural steroid Other interventions - e.g. Pilates,
injections are not recommended for WAD Feldenkrais, Alexander Technique,
Grade I or WAD Grade II. Occasionally, WAD Grade III with unresolved radicular pain massage and homeopathy
of more than one month might benefit from Pilates, Feldenkrais, Alexander Technique, epidural steroid injections.
massage and homeopathy are not There is no indication for steroid trigger point injection in the ‘acute' phase (less than threeweeks). Because harmful side effects of Not relevant to acute WAD Grades I, II or III Injections - sterile water injections
Injections - local anaesthetic nerve
blocks
Not included. Not relevant to management ofacute WAD Grades I to III.
Not included. Not relevant to management ofacute WAD Grades I to III.
Purpose of the guidelines The guidelines are intended to assist health professionals delivering primary careto 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 The QTF6 definition of Whiplash-AssociatedDisorders (WAD) has been adopted as the No complaint about the neck.
definition of acute or sub-acute simple neck No physical sign(s).
pain for the purposes of these guidelines.
Neck complaint of pain, stiffness or Whiplash is an acceleration-deceleration tenderness only.
mechanism of energy transfer to the neck. No physical sign(s).
It may result from ".motor vehiclecollisions." The impact may result in bony Neck complaint AND or soft tissue injuries,7 which in turn may lead to a variety of clinical manifestations Musculoskeletal signs include decreased range of motion and pointtenderness.
Neck complaint AND neurological The scope of the guidelines covers WAD Grades I, II and III following a motor vehicle collision.
Neurological signs include decreasedor absent deep tendon reflexes, These guidelines are applicable in the first weakness and sensory deficits.8 twelve weeks when WAD is the only injury orwhen it has occurred concurrently with other Neck complaint AND fracture or dislocation.
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.
6, 7, 8 See Notes, page 43 When to consult the guidelines
Target audience and products
An example of appropriate use of the The primary target audience for the clinical guidelines is a situation in which an adult who practice guidelines is general practitioners in is experiencing neck pain after a recent motor New South Wales. The guidelines will be vehicle collision consults his or her general relevant to other health professionals involved practitioner. The guidelines would be relevant in primary care in New South Wales, e.g.
during the period when the doctor: physiotherapists, chiropractors and osteopaths.
• takes a history Companion documents have also been • conducts an examination developed for consumers, and for claims • determines what, if any, investigations are officers in the compulsory third party insurance industry in New South Wales.
• treats or refers for treatment from other health A technical report containing the tables of professionals such as physiotherapists and evidence and a detailed description of the methodology used to adapt the QTF guidelinesfor use in New South Wales has also been In many cases, recovery from WAD occurs quickly; however, it is recognised that somepeople with WAD will require treatment and Titles of the five documents are as follows: support beyond 12 weeks.
• Guidelines for the Management of Whiplash-Associated Disorders – for To deal with more complex cases the guidelines health professionals. offer ways to take action, by: • SUMMARY Guidelines for the Management of • alerting primary health care professionals to adverse prognostic indicators (yellow flags)which may indicate the need for more • Your Guide to Whiplash Recovery – for intensive treatment or early referral.
• confirming that the diagnosis of a fracture or • Compulsory Third Party Claims Guide to the dislocation warrants immediate referral to an Management of Whiplash-Associated Accident and Emergency Department or a Disorders – for the compulsory third party specialist surgeon.
insurance industry. • providing indications of durations when • TECHNICAL REPORT Update of QTF referral to specialists or multi-disciplinary pain Guidelines for the Management of Whiplash- team or rehabilitation providers should be Associated Disorders. Copies are available from the Motor AccidentsAuthority.
A detailed account of the process by which these consensus guidelines weredeveloped is described separately in Technical Report: Update of Quebec TaskForce Guidelines for the Management of Whiplash-Associated Disorders.
The methodology was guided by National • Consultations on the draft clinical guidelines Health and Medical Research Council were undertaken with industry representatives recommendations9 for the development of and consumers in order to develop clinical practice guidelines. The following companion documents for claims managers in approach was taken: the compulsory third party insurance industry • Recommendations contained in the guidelines and for consumers.
developed by the QTF and published in 1995 • The clinical guidelines were substantially were taken as the starting point. reworked in the light of public comment.
• A literature review was undertaken to collect Changes included: information on additional evidence which – providing more information about the was both relevant to the scope of these standing of the QTF guidelines, including guidelines and which had been published after the evidence was collected by the QTF – providing more information on the basis (i.e. after 1993). The NHMRC for changes made to the QTF recommendations for the review of evidence are summarised on the next page.
– improving the layout of the document to • Tables of evidence were prepared which: make it easier for primary health care – summarise the literature identified, and practitioners to use – rate the new evidence provided by the – modifying some recommendations.
review: from I, the highest quality, to IV, • The four documents were then sent to three the lowest quality. In rating the evidence experts for review – two reviewers overseas the Working Party was guided by NHMRC and one in Australia.
recommendations, summarised on the • Overall the comments of the reviewers were positive. Further changes made to incorporate • QTF recommendations were reviewed in the reviewers' comments were: light of this evidence, and in the absence of – providing more information about the any further evidence, the opinion of the limitations of the QTF guidelines Technical Group, a sub-set of the WorkingParty. Criteria taken into account in making – adding a recommendation that patients these recommendations were: opinion on should be reassured as part of their efficacy and safety.
• The draft developed by the Technical Group – recommending that psychological and was reviewed by the broader Working Party.
psychosocial factors should be recorded aspart of history taking and added as • The draft clinical guidelines were then sent prognostic indicators out to a range of medical and healthorganisations and individuals for comment.
– recommending rehabilitation programs for those unable to return immediately to theirusual activities.
9 See Notes, page 43 • The four documents were then sent as final • During the period of public comment and drafts to the MAA Advisory Council for expert review an implementation and evaluation strategy was developed.
NHMRC methodology for review
NHMRC rating scale for quality
of evidence
of evidence
Key characteristics of this approach: • Clearly stated title and objectives for the Evidence obtained from a systematic review of all relevant randomised controlled trials.
• Comprehensive strategy to search for studies that address the objectives of the review Evidence obtained from at least one properly (relevant studies) to include unpublished as designed randomised controlled trial.
well as published studies.
• Explicit and justified criteria for the Evidence obtained from well-designed inclusion or exclusion of any study.
pseudo-randomised controlled trials. • Comprehensive list of all studies identified.
• Clear presentation of the characteristics of Evidence obtained from comparative studies each study included and an analysis of with concurrent controls and where allocation is not randomised (cohort studies), • Comprehensive list of all studies excluded case-control studies, or interrupted time and justification for exclusion.
series with a control group.
• Clear analysis of the results of the eligible studies using statistical synthesis of data Evidence obtained from comparative studies (meta-analysis), if appropriate and possible.
with historical control, two or more single- • Sensitivity analyses of the synthesised data if arm studies, or interrupted time series appropriate and possible.
without a parallel control group.
• Structured report of the review clearly stating the aims, describing the methods and Evidence obtained from a case series, either materials and reporting the results.
post-test or pre-test and post-test.
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 explanationof any change to that recommendation.
Additional evidence located by the literature The Technical Report, also published by the review covering 1993 to 1999 in relation to this MAA, provides titles and further details of subject is then summarised and the level of these studies.
evidence provided by this research is rated.
Finally there is a justification for any changesmade to the QTF recommendation.
Diagnosis of Whiplash-Associated Disorders • circumstances of injury (sport, motor vehicle); mech- Working Party recommendations
anism of injury, e.g. if the head moved for clinical practice
forwards, backwards, sideways or all of these; how History taking is important during all visits for the the accident occurred; the position of the person in treatment of WAD patients of all Grades.
the car, i.e. passenger or driver; body position; typeof vehicle involved The history should include information about: • results of assessments conducted using tools to • date of birth, gender, occupation, number of measure general psychological state and pain and dependants, marital status disability outcomes, e.g. the General Health • prior history of neck problems including previous Questionnaire (GHQ), a visual analogue pain scale or a neck disability index; examples of these are • prior history of psychological disturbance available from the MAA.
• prior history of long-term problems in adjusting History details should be recorded. A standard form may be used.
• current psychosocial problems, e.g. family, job- related, financial problems Quebec Task Force (QTF) recommendations for • symptoms including pain, stiffness, numbness, weakness and associated extracervical symptoms – clinical practice localisation, time of onset and profile of onset History taking is important during all visits forthe treatment of WAD patients of all Grades. should be recorded for all symptoms The history should include information about: • older age (Harden S et al., 1998; Hartling L et • date of birth, gender, occupation, number of al., 1999; Smed A, 1997; Radanov BP, 1994 dependants and marital status • prior history of neck problems, including • female gender (Harden S et al., 1998; Smed previous whiplash • symptoms including pain, stiffness, numbness, • not in full-time employment (Harden S et al., weakness and associated extracervical • having dependants (Harden S et al., 1998) • circumstances of injury (e.g. sport, motor • insurance/compensation – presence of; type of system (Cassidy D et al., 1999)10 • mechanism of injury. • head rotated or inclined at time of impact (Radanov BP, 1995; Haden S et al., 1998); This minimal history should be recorded on a occupancy in truck/bus; being in head-on or standard form.
perpendicular collision (Radanov BP 1995) Basis of QTF recommendations • pre-traumatic headaches (Radanov B P, 1994 Twenty studies dealing with aspects of thepatient history in diagnosis of WAD were • previous history of head injury (Radanov BP, reviewed. No accepted study dealt with the value of history taking for the positive diagnosis Evidence of psychosocial factors was conflicting (Radanov BP 1994 and 1995; Karlsbourg et al., These recommendations are based on the 1997; Heikkila H et al., 1998). Cassidy (1999) consensus of the Task Force.
found that the incidence rate of claims was lessin a no fault scheme compared to a tort scheme.
Additional evidence Rating of additional evidence: III–2 for adverse No additional study was identified that dealt with the value of history taking for positive Noted that for research on prognosis a well- diagnosis of WAD.
designed cohort study is the highest possible There are cohort studies considering prognostic level of evidence.
indicators of WAD that are relevant to historytaking (see below for details of studies). Poor Basis for changes to QTF recommendations outcome/delayed recovery has been associated By consensus of the Working Party, reference to with several variables including: validated tools for measuring pain and neck • severity of neck symptoms and radicular disability was added in response to public irritation at initial assessment (Radanov BP, comment. By consensus of the Working Party pychosocial factors (prior history of • presence of specific symptoms such as psychological disturbance, prior history of long- headache; muscle pain; pain or numbness term problems in adjusting to symptoms and radiating from neck to arms, hands or current psychosocial problems, e.g. family, job- shoulders (Radanov BP, 1994) related, financial problems) and examples ofmechanism of injury were included in response • history of pre-traumatic headaches or past to comment from an expert reviewer. As well it head injury (Radanov BP, 1994 and 1995) was stated that a standardised form "may be" • initial injury reaction (sleep disturbance, used rather than "should be" used.
nervousness) (Radanov BP, 1994) • more initial subjective complaints and concern regarding long-term prognosis(Radanov BP, 1995) • pre-existing osteoarthritis (Radanov BP, 1995) 10 See Notes, page 43 Recommendations for clinical practice (continued) Basis of QTF recommendationsEighteen studies dealing with aspects ofphysical examination of WAD patients were Working Party recommendations
reviewed. No accepted study dealt with thevalue of physical examination for the positive for clinical practice
diagnosis of WAD.
These recommendations are based on the A focused physical examination is necessary for all consensus of the Task Force.
patient visits. The physical examination should includeat least: Additional evidence No accepted additional study was identified thatdealt with the value of physical examination for • palpation for tender points the positive diagnosis of WAD.
• ROM in flexion-extension, rotation and lateral flexion There are cohort studies considering prognostic • neurological examination to assess sensorimotor func- indicators of WAD that are relevant to physical tion and tendon reflexes of upper and lower limbs examination. One cohort study of 50 patientspresenting to an accident and emergency • assessment of associated injuries department found that a diminished range of • assessment of general medical condition as needed, neck movements and poor psychological state,as measured by the General Health including mood, affect and psychological state.
Questionnaire (GHQ 28), at three months was • a universal goniometer can be used to measure predictive of intrusive or disability symptoms at neck ROM, and/or a hand-held dynamometer can two years (Gargan M et al., 1997). In oneseven-year cohort study of 2,627 subjects, be used to measure strength.
authors concluded that patients presenting with Both positive and negative findings should be several specific musculoskeletal (neck pain on recorded. A standard form may be used.
palpation) and neurological signs andsymptoms may have a longer recovery period(Suissa S, 1999). QTF recommendations for clinical practice Rating of additional evidence: IV for tendernessto palpation, neurological signs, ROM and A focused physical examination is necessary during all patient visits. The physicalexamination should include at least: Basis for changes to QTF recommendations "Mood, affect and psychological state" was • palpation for tender points added to physical examination on the basis of • assessment of range of motion in flexion- level IV evidence. In response to public extension, rotation and lateral flexion comment the Working Party agreed to include • neurological examination to assess reference to the use of goniometers and sensorimotor function and tendon reflexes of dynamometers. As well it was stated that a upper and lower limbs standard form "may be" used rather than"should be" used.
• assessment of associated injuries • assessment of general medical condition, as The addition of the phrase "both positive and negative findings" before "should be recorded"was based on the comments of an external Results of the minimal physical examination reviewer and Working Party consensus.
should be recorded on a standard form.
Plain radiographs
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, are Working Party recommendations
not obtunded by narcotics or other drugs, and for clinical practice
who show no physical signs on examination,require no plain radiographs on presentation.
Basis of QTF recommendations WAD Grade I patients who are conscious, show no Sixty-one studies dealing with plain radiographs signs of alcohol-related impairment, are not obtunded in WAD patients were reviewed. No accepted by narcotics or other drugs, who show no physical study dealt with the value of plain radiographs signs on examination, have not been involved in a for the diagnosis of WAD.
high speed or high impact injury, or in a collision Plain radiographs are not useful for the where another occupant has been killed, require no diagnosis of WAD Grades I, II and III.
Radiographs are needed to diagnose bony plain radiograph on presentation.
lesions of WAD Grade IV. There is suggestion inthe literature that patients with WAD Grade I and no other injury, with no midline cervical In patients presenting as WAD Grade II, plain X-rays pain, with normal alertness and attention, and of the cervical spine should be taken if the severity who are not obtunded by narcotics, alcohol, orother drugs, may not need radiographs. The of the signs on examination suggest the possibility of small sample size of these studies and the a bony injury, or if their level of consciousness, or resulting uncertainty around estimates of false pain sensation is impaired by brain injury or alcohol negative and positive rates made it impossible or other drugs, or if they have been involved in high to make recommendations about plainradiographs on the basis of scientific data.
speed or high impact injury, or in a collision whereanother occupant has been killed. Flexion and Recommendations regarding plain radiographsin diagnosis of WAD are based on the extension views may occasionally be indicated.
consensus of the Task Force.
Additional evidence All patients who present with WAD Grade III should No accepted additional study was identified that have baseline radiological investigation of the cervical dealt with the value of plain radiographs for the spine including anterior-posterior, lateral and open- positive diagnosis of WAD. mouthed views. All seven cervical vertebral and the With regard to usefulness of plain radiographs, C7-T1 disc should be well visualised. Flexion-extension there was one observational study of 669 views may occasionally be indicated.
subjects 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 QTF recommendations for clinical practice X-rays (Brison R et al., 1999). A cohort study of117 subjects identified that poor outcome was All patients who present with WAD Grades II associated with more signs of pre-existing and III should have baseline radiological cervical spine osteoarthritis on initial X-ray examination of the cervical spine. This (Radanov BP 1995). In another cohort study of examination should include anteroposterior, 100 subjects authors concluded that kyphotic lateral and open-mouth views. All seven angle seen on functional views does not indicate cervical verterbral and the C7-T1 disc space soft tissue injury (Ronnen HR et al., 1996). should be well visualised. Recommendations for clinical practice (continued) Plain radiographs (continued)
Basis of QTF recommendationsOne study dealing with tomograms, 10 studies Rating of additional evidence: IV for a of CT scan, five studies of MRI, one study of conservative approach to radiological myelography, one study of discography, three studies of scintigraphy, and no studies ofaniography were reviewed.
Basis for changes to QTF recommendations No accepted studies dealt with CT scans in WAD The recommendation was re-organised for patients; one study dealt with MRI, but did not clarity. The requirement for plain X-rays of the provide any evidence that this technique might cervical spine for WAD Grade II was be useful for the diagnosis of WAD.
downgraded to specifying the circumstances inwhich this would be required. The basis for this Specialised imaging techniques are not useful for was level IV evidence. The requirements for the positive diagnosis of WAD Grades I to III.
radiological investigation for high speed, high Specialised imaging techniques might be impact collisions, or those where another necessary, in some instances, to make the occupant has been killed, were added for positive diagnosis of WAD Grade IV.
consistency with the Royal Australasian Collegeof Surgeons guidelines for trauma management.
Therefore, these recommendations are based onTask Force consensus.
Specialised imaging techniques
Additional evidence One two-year cohort study of 52 subjects Working Party recommendations
suggested no benefit in using MRI for commonneck hyperextension-flexion injuries for clinical practice
(Borchgrevink GE et al.,1995). A cohort study of43 subjects over seven months reportedcorrelation between MRI and clinical findings WAD Grades I and II was poor (Karlsborg et al., 1997). In an There is no role for specialised imaging techniques observational study of 39 subjects authors (e.g. tomography, CAT scan, MRI, myelography, concluded that relationship between MRI discography etc.) in WAD Grades I and II.
findings and the clinical symptoms and signs ispoor (Pettersson K et al., 1998). An observational study of 100 acute whiplash injurypatients suggested that there is no role for MRI Specialised imaging techniques might be used in in routine work-up of acute whiplash injury selected WAD Grade III patients, e.g. nerve root when patients have normal radiographs and/or compression or suspected spinal cord injury, on the no evidence of a neurological deficit (RonnenHR et al., 1996).
advice of a medical or surgical specialist.
In conclusion there is evidence (Level IV) toindicate that MRIs are not useful in predicting QTF recommendations for clinical practice outcomes in WAD Grades I to III.
Rating of additional evidence: IV There 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 patientsbased on the advice of an accredited medical orsurgical specialist.
Basis for changes to QTF recommendations Basis of QTF recommendations The recommendations were reorganised for The QTF examined one study dealing with clarity. Additional information was provided on evoked potentials (SSEP). No accepted study when special imaging techniques might be dealt with evoked potential in WAD.
appropriate to improve usefulness to clinicians.
The QTF examined four studies of selective Examples given were based on consensus of nerve root blocks and two studies of EMG.
the Working Party.
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 Working Party recommendations
audiology or visual examinations. There were for clinical practice
no accepted studies of any of these specialexaminations in patients with WAD.
Considered by Working Party as not relevant to Therefore all recommendations regarding these management of WAD Grades I to III. Examples include specialised examinations are based on theconsensus of the Task Force.
EEG, EMG and specialised peripheral neural tests.
Additional evidence QTF recommendations for clinical practice Not included. Not relevant to management ofWAD Grades I–III. Indications for evoked potentials (SSEP) in WADGrade III patients should be based on the Basis for changes to QTF recommendations advice of an accredited medical or surgical Considered by Working Party as not relevant to management of WAD Grades I–III. It was Indications for selective nerve root blocks and agreed to provide examples of specialised of EMG in WAD Grades II and III patients examinations – EEG, EMG, and specialised should be based on the advice of a medical or peripheral neural tests.
surgical specialist. Indications for other specialised examinations inWAD patients should be based on the advice ofan accredited medical or surgical specialist.
Recommendations for clinical practice (continued) Prognosis of Whiplash-Associated Disorders Additional evidenceSee ‘History taking' page 18.
Working Party recommendations
Basis for changes to QTF recommendation for clinical practice
Level III-2 evidence for adverse prognosticindicators (yellow flags). Working Partyconsensus was the basis for adding action Poor outcome has been associated with: following identification of yellow flag/s.
• severity of neck symptoms and radicular irritation at initial assessment • presence of specific symptoms such as headache; muscle pain; pain or numbness radiating from neck Working Party recommendations
to arms, hands or shoulders for clinical practice
• history of pre-traumatic headaches • previous history of head injury Poor outcome may be associated with pre-existing • initial injury reaction (sleep disturbance, osteoarthritis on the initial cervical radiograph.
This yellow flag factor should alert the practitioner to the • more initial subjective complaints and concern potential need for more intensive treatment or earlier referral.
regarding long-term prognosis • pre-existing osteoarthritis QTF findings Although several accepted studies addressed • head rotated or inclined at time of impact; radiological findings, none of the results are occupancy in truck/bus; being in head-on or Additional evidence These yellow flag factors should alert the practitioner to the One study showed that presence of pre-existing potential need for more intensive treatment or earlier referral.
osteoarthritis on the initial cervical radiograph wasa poor prognostic indicator (Radanov BP, 1995). Rating of additional evidence: IV Three accepted studies provide information on Basis for changes to QTF recommendations symptoms that are useful for predictingrecovery. These studies did not cover similar Level IV evidence for adverse prognostic symptoms and outcome measures. Similarly, indicator (yellow flag). Consensus of Working only one accepted study provided useful Party for action following identification of information about signs of prognostic value.
yellow flag.
Therefore, the QTF recommendations are basedon both evidence and the Task Force consensus.
Working Party recommendations
Working Party recommendations
for clinical practice
for clinical practice
Poor outcome may be associated with: In addition to the fact that management of thiscondition, by definition, is taking place in the context • prior history of psychological disturbance – these of compensation (recognised as an adverse prognostic disturbances may be indicative of a proneness to indicator), other socio-demographic indicators emotional/affective problems and somatisation associated with poor outcome are: reactions, which are frequently based on affectivedisorders. Somatisation reaction in the course of WAD may establish a basis for symptom • female gender augmentation, if not identified early, this is • not in full-time employment frequently not treated properly and may lead to • having dependants These yellow flag factors should alert the practitioner to the • prior history of long-term problems in adjusting to potential need for more intensive treatment or earlier referral.
symptoms of an injury or illness, e.g. copingmechanisms • current psychosocial problems, e.g. family, job- related, financial problems.
QTF findings Of the 11 studies accepted, two provided data These yellow flag factors should alert the practitioner to the on potential predictive factors.
potential need for more intensive treatment or earlier referral.
QTF recommendation is based on both evidenceand the Task Force consensus.
QTF recommendations for clinical practice Additional evidence Not included.
See ‘History taking' page 18.
Basis of QTF recommendations Basis for changes to QTF recommendations Not included.
Level III-2 evidence for adverse prognosticindicators (yellow flags). Consensus by Working Additional evidence Party for action following identification of No additional evidence was found concerning yellow flag/s.
the independent effect of reassurance on WAD. Basis for changes to QTF recommendationsConsensus of the Working Party members basedon comments of expert reviewer.
Recommendations for clinical practice (continued) Treatment of Whiplash-Associated Disorders Act as usual
Working Party recommendations
Working Party recommendations
for clinical practice
for clinical practice
The practitioner should reassure the patient – by Act as usual – should be used as a treatment for acknowledging that the patient is hurt and has WAD with or without pain relief as per symptoms, and advising that: recommendations regarding pharmacology – • symptoms are a normal reaction to being hurt, see page 28.
• it is important to focus on improvements in QTF recommendations for clinical practiceNot included.
• maintaining life activities is an important factor in getting better.
Basis of QTF recommendationsNot included.
QTF recommendations for clinical practice Additional evidence Not included.
One RCT of 201 WAD subjects suggested asignificantly better outcome for the ‘act as usual Basis of QTF recommendations group' (self-training and a five-day prescriptionfor NSAIDs) in terms of subjective symptoms in Not included.
comparison to the other group who wore acollar and were put on sick leave for 14 days Additional evidence (Borchgrevink GE et al., 1995).
No additional evidence was found concerning Rating of additional evidence: II for act as usual the independent effect of reassurance on WAD. advice plus self-training and NSAIDS.
Basis for changes to QTF recommendations Basis for changes to QTF recommendations Consensus of the Working Party members.
Level II evidence.
Miscellaneous interventions
Basis for changes to QTF recommendations - prescribed function, work alteration,
Consensus of the Working Party members was acupuncture and relaxation techniques
based on comments of expert reviewer.
Acupuncture is addressed in separaterecommendation on page 32.
Working Party recommendations
Manual and physical therapies
for clinical practice
- exercise
Prescribed function, i.e. return to usual activity as Working Party recommendations
soon as possible, is recommended. Rehabilitation for clinical practice
programs, which may include work alteration andrelaxation techniques, may assist recovery dependingon symptoms (e.g. pain, ability to concentrate) and ROM (range of movement) exercises, muscle re-education and low load isometric exercise torestore appropriate muscle control and support to the QTF recommendations for clinical practice cervical region, should be implemented immediately, if necessary in combination with intermittent rest when • WAD Grade I – prescribed function, i.e.
pain is severe. Clinical judgment is crucial if immediate return to usual activity, is symptoms are aggravated.
recommended. Neck school, work alteration,acupuncture and relaxation techniques arenot indicated for Grade I.
• WAD Grades II and III – prescribed function, QTF recommendations for clinical practice i.e. return to usual activity, is encouraged as Evidence based – there is insufficient evidence soon as possible. Neck school, temporary assessing the independent contribution of work alteration, acupuncture and relaxation techniques are optional adjuncts for symptom Consensus based – ROM exercises should be duration more than three weeks.
implemented immediately, in combination ifnecessary with intermittent rest, when pain is Basis of QTF recommendations severe. Clinical judgment is crucial if symptoms No additional evidence was found concerning are aggravated.
these treatments.
Basis of QTF recommendations Additional evidence No evidence was found regarding independent No additional evidence was found regarding benefit of exercise in WAD.
use of these treatments in acute WAD. Prescription of home exercise combined with One expert reviewer referred to a study of activation advice, was found to have short- and patients with minor head injuries (many of long-term benefit for WAD presenting within whom have similar problems to whiplash four days of injury.
patients)11 which describes the importance ofgradual return to regular activities. The strategy Additional evidence described in the study was ‘individually tailored' No additional evidence was found regarding and mainly considered the patients' effective independent benefit of exercise in WAD. level of functioning. It showed considerableadvantages in long-term outcome whencompared to arbitrary schemes.
11 See Notes, page 43 Recommendations for clinical practice (continued) Manual and physical therapies
QTF recommendations for clinical practice - exercise (continued)
Consensus based – no medications should beprescribed for WAD Grade I. Non-narcotic A Cochrane Review (1998) on physical analgesics and NSAIDs can be used to alleviate medicine modalities for management of pain for the short term in WAD Grades II and mechanical neck disorders concluded there was III. Their use should not be continued for more lack of scientific evidence to determine the than three weeks, and should be weighed efficacy of exercise (Gross AR et al., 1998).
against possible side effects. Narcotic analgesicsshould not be prescribed for WAD Grades I and Basis for changes to QTF recommendations II. Occasionally they may be prescribed for pain "Muscle re-education and low load isometric relief in acute severe WAD Grade III, but only exercise" were added to the QTF for a limited period of time. Although commonly recommendation relating to ROM exercise by prescribed, muscle relaxants should not consensus of the Working Party.
generally be used in the acute phase of WAD. The psychopharmacologic drugs are not recommended for use on a general basis inWAD of any duration or Grade, but they maybe used occasionally for symptoms such as Working Party recommendations
insomnia or tension, as an adjunct to activatinginterventions in the acute phase (less than three for clinical practice
months duration).
For chronic pain in WAD (more than three months' duration), the minor tranquillisers and No medication other than simple analgesics should be antidepressants may be used.
Basis of QTF recommendations WAD Grades II and III No evidence was found regarding the benefit ofnarcotic analgesics or psychopharmacologics in Non-opioid analgesics and NSAIDs can be used to WAD. No studies were accepted regarding the alleviate pain for the short term. Their use should be benefit of muscle relaxants in WAD.
limited to three weeks and should be weighed Analgesics or NSAIDs in combination with other against possible side effects.
treatment modalities were found to be of short-term benefit in WAD Grades I and II presenting Opioid analgesics are not recommended for WAD within three days of injury (see activation, Grades I and II. They may be prescribed for pain relief in acute severe WAD Grade III for a limitedperiod of time.
Additional evidenceA RCT of WAD Grades I and II given Muscle relaxants should not generally be used in Tenoxicam 20 mg within 72 hours of injury had acute phase WAD.
better ROM and less pain at 15 days comparedto control (Gunzburg R, 1999). Psychopharmacologic drugs are not recommended in A small RCT of WAD Grades II and III subjects WAD of any duration or grade; however, they may be suggested those treated with high dose 24-hour used occasionally for symptoms such as insomnia or methylprednisolone infusion (as per acute tension or as an adjunct to activating interventions spinal cord trauma protocol) had less sick leave in the acute phase (less than three months' duration).
compared to controls (Pettersson K & ToolanenG, 1998). Use of high dose IV methylprednisolone infusion for Rating of additional evidence: II for use of acute management of WAD Grades II and III is not Tenoxicam and for methylprednisilone infusion.
Basis for changes to QTF recommendations The Working Party did not consider the use ofhigh dose IV methylprednisilone infusion, given WAD Grade I – prescription of simple the potential adverse effects, could be justified analgesics was included by consensus of the on the basis of a small RCT.
Working Party.
Recommendations regarding the WAD Grades II and III – unchanged but pharmacological management of chronic pain reorganised. Working Party preferred the term are not included as this is outside the scope of "opioid" to "narcotic".
the guidelines.
"Occasionally" was deleted for consistency withNHMRC Guidelines for the management of pain.12 12 See Notes, page 43 Recommendations for clinical practice (continued) Treatment of Whiplash-Associated Disorders Recommended under certain circumstances Manual and physical therapies
Rating of additional evidence: II for the effect of - postural advice
physical modalities, ROM exercise, mobilisation;and physiotherapist advice on posture and ROM exercise.
Working Party recommendations
Basis for changes to QTF recommendations for clinical practice
Recommendation unchanged other thanreplacing the term "activation" with "manualand physical therapies and exercise".
Postural advice can be given in combination withmanual and physical therapies and exercise in WAD.
Manual and physical therapies
- mobilisation
QTF recommendations for clinical practiceConsensus based – postural advice can be given Working Party recommendations
in combination with activation in WAD.
for clinical practice
Basis of QTF recommendations Mobilisation can be used for WAD, providing there is No evidence was found concerning theindependent therapeutic effect of postural evidence of continuing improvement with the alignment in WAD.
treatment. If mobilisation is used it should be Advice on posture, combined with advice on commenced early, within the first seven days. This activation for WAD presenting within four days technique should be restricted to registered health of injury, has short- and long-term benefit.
practitioners trained in the specific methods and When combined with physiotherapy, soft collarand analgesics, there was only short-term according to current professional standards.
Additional evidence QTF recommendations for clinical practice No additional evidence was found concerning Evidence based – there is weak cumulative the independent therapeutic effect of postural evidence to support their combined use in WAD.
alignment in WAD.
Consensus based – a regimen of mobilisation In one RCT, Mealy et al., divided subjects into can be used for WAD.
Basis of QTF recommendations • Group 1 = analgesics plus rest; No evidence was found concerning the • Group 2 = analgesics plus physical modalities, independent effect of mobilisation on WAD.
ROM exercises and mobilisation; • Group 3 = analgesics plus collar plus Manual mobilisation combined with other physiotherapy advice on mobilisation, posture physiotherapeutic interventions in WAD and ROM exercises. presenting within four days of injury and inneck pain syndromes of indeterminate duration, At two years, Group 3 had fewer symptoms. At was shown to have short-term benefit; long- two years, Group 3 had less pain than Groups 1 term results are no better than those for and 2 (in Hurwitz ET et al., 1996). combined collar, rest and analgesics.
Additional evidence QTF recommendations for clinical practice No additional evidence was found concerningthe independent effect of mobilisation on WAD. Consensus based – a short-term regime ofmanipulation can be used for WAD. This A major systematic review of manipulation and technique should be restricted to registered mobilisation of cervical spine for treatment of health practitioners trained in the specific mechanical neck pain and headache published methods and according to current professional in 1996 concluded that these modalities provide short-term benefit and that more high qualityresearch is required (Hurwitz ET et al., 1996).
Basis of QTF recommendations Three RCTs reviewed found that mobilisationfor acute neck pain provided short-term benefit No evidence was found addressing the short- or (McKinney LA, 1989; McKinney LA et al., 1989; long-term benefits of a complete course of Mealy K et al., 1986). manipulative therapy on WAD.
Mealy K et al., divided subjects into three The immediate effect on pain and ROM of a single manipulation is similar to that of a singlemobilisation in neck pain of varying duration.
• Group 1 = analgesics plus rest; There is insufficient evidence assessing the • Group 2 = analgesics plus physical modalities, independent contribution of this technique.
ROM exercises and mobilisation; • Group 3 = analgesics plus collar plus Additional evidence physiotherapy advice on mobilisation, posture No additional evidence was found concerning and ROM exercises. the independent effect of manipulation onWAD. At two years, Group 3 had fewer symptoms. Attwo years, Group 3 had less pain than Groups 1 A major systematic review of manipulation and mobilisation of cervical spine for treatment ofmechanical neck pain and headache published Rating of additional evidence: II for short-term in 1996 concluded that these modalities provide benefit of mobilisation.
short-term benefit and that more high quality Basis for changes to QTF recommendations research is required (Hurwitz ET et al., 1996).
No RCTs were found examining manipulation Level II evidence to support short-term benefit for acute neck pain.
of mobilisation for acute neck pain.
Basis for changes to QTF recommendations Consensus of Working Party members.
- traction
Working Party recommendations
for clinical practice
Working Party recommendations
A regime of manipulation can be used for WAD, for clinical practice
providing there is evidence of continuing improvementwith the treatment. This technique should berestricted to registered health practitioners trained in A regime of traction can be used in combination the specific methods and according to current with other mobilising modalities in WAD providing professional standards. Complications from there is evidence of continuing improvement with the manipulation are rare, but include stroke and death.
WAD Grade III (decreased or absent deep tendonreflexes and/or weakness and sensory deficit) is arelative contra-indication for manipulation.
Recommendations for clinical practice (continued) - traction (continued)
QTF recommendations for clinical practiceEvidence based – there is weak evidence that Working Party recommendations
traction is of short-term benefit.
for clinical practice
Consensus based – a regime of traction can beused in combination with other mobilising A multimodal treatment program can be used for interventions in WAD.
WAD which has not settled within four to six weeks Basis of QTF recommendations providing there is evidence of continuing improvementwith the treatment.
No evidence was found addressing independenteffects of traction in WAD.
Traction in combination with other QTF recommendations for clinical practice physiotherapeutic interventions was found to be Not included.
of short-term benefit in WAD presenting withinfour days of injury, and in neck pain syndromesof indeterminate duration; there was no long- Basis of QTF recommendations term (two year) benefit for WAD presenting Not included.
within four days of injury.
Additional evidence In a small RCT, there were no statisticallysignificant differences between static, One RCT of 60 WAD patients suggested intermittent and manual traction in combination improved pain, disability and return to work for with other physiotherapeutic interventions in multimodal treatment group compared to neck pain syndromes of indeterminate duration.
control group that received physical modalitiesalone (Provenciali L et al., 1996).
Additional evidence Rating of additional evidence: II for multimodal No additional evidence was found addressing independent effects of traction in WAD. Basis for changes to QTF recommendations A Cochrane Review (1998) on physicalmedicine modalities for mechanical neck Level II evidence to support use of this disorders concluded that lack of scientific treatment. Recommendations regarding testing prevented determination of efficacy of appropriate time to commence and the need for traction (Gross AR et al., 1998). An earlier monitoring were based on Working Party systematic review on traction for neck and back pain 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.
Passive modalities/electrotherapies
- heat, ice, massage, TENS, PEMT,
electrical stimulation, ultrasound,
Working Party recommendations
laser, short-wave diathermy
for clinical practice
A regime for acupuncture can be used in WAD Working Party recommendations
providing there is evidence of continuing improvement for clinical practice
with the treatment.
QTF recommendations for clinical practice Although active PEMT in a soft collar was better than sham PEMT in a soft collar, PEMT is notrecommended because it involves wearing a soft Acupuncture is not recommended for WADGrade I (see also page 27 Miscellaneous collar eight hours a day for 12 weeks.
WAD Grades II and III WAD Grade II and III During the first three weeks the other professionally Prescribed function, i.e. return to usual activity, administered passive modalities/electrotherapies are is encouraged as soon as possible, temporary optional adjuncts to manual and physical therapies work alteration, relaxation techniques and and exercise with emphasis on return to usual acupuncture are optional adjuncts for
symptom duration greater than three weeks.
activity as soon as possible.
Basis of QTF recommendations QTF recommendations for clinical practice One accepted RCT was found for chronic neckpain (daily neck pain with or without radiation more than six months). The study suggested • WAD Grade I: although active PEMT in a soft that acupuncture and NSAIDs or analgesics collar was better than sham PEMT in a soft were not better than sham TENS with NSAIDs collar, PEMT is not recommended because it or analgesics for relief of pain.
involves wearing a soft collar eight hours aday for 12 weeks. Additional evidence • WAD Grades II and III: the other No additional evidence was found professionally administered passive independently examining use of acupuncture in modalities/electrotherapies are optional adjuncts during the first three weeks toactivating interventions with emphasis on A Cochrane Review (1998) on use of return as soon as possible to usual activity.
acupuncture in neck disorders concluded therewas insufficient quality research to comment on Basis of QTF recommendations effectiveness of acupuncture (Gross AR et al.,1998).
There were virtually no accepted studiesaddressing the benefit of these modalities.
Basis for changes to QTF recommendations Two small RCTs in WAD Grades I and II Given the lack of evidence on the effectiveness presenting less than 72 hours, and in neck pain of acupuncture for WAD, by consensus the not related to WAD more than eight weeks' Working Party agreed that acupuncture should duration, suggest a benefit from PEMT only be continued if there was evidence of compared with sham PEMT in pain control improvement in individual cases.
Recommendations for clinical practice (continued) Prescribed rest for 10 to 14 days in combination with soft collars and analgesia in WAD wasassociated with delayed recovery.
when combined with NSAIDs, activating adviceand soft collar.
Additional evidenceIn a RCT of 201 acute whiplash subjects it was All modalities except laser were possible adjuncts demonstrated that an ‘act as usual' group had to mobilising interventions, which had short-term better outcomes in terms of subjective benefit equivalent to activation advice.
symptoms compared to subjects managed with There were no accepted studies in which the 14 days' sick leave and immobilisation with soft benefits of laser were addressed.
neck collar (Borchgrevink GE, 1998).
Rating of additional evidence: II Additional evidenceNo additional accepted studies independently Basis for changes to QTF recommendations assessing the use of these modalities in acute WAD Grade I to III were found. Comment: the additional evidence referred to Basis for changes to QTF recommendations above would suggest that for many cases "actas usual" should be recommended, and The only change is the use of the terms therefore an additional recommendation has "manual and physical therapies and exercise" been added to this effect, see page 26.
instead of "activating interventions".
- collars
Immobilisation - prescribed rest
Working Party recommendations
Working Party recommendations
for clinical practice
for clinical practice
Collars should not be prescribed.
Rest should not be prescribed for WAD Grade I.
WAD Grades II and III WAD Grades II and III If prescribed for WAD Grades II or III, they should Rest for more than four days should not be not be used for more than 72 hours.
prescribed for WAD Grades II and III.
QTF recommendations for clinical practice QTF recommendations for clinical practice Evidence based – there is weak cumulative Evidence based – there is weak cumulative evidence to restrict prescribed rest to short evidence to restrict their use to short periods of periods of time.
Consensus based – rest should not be Consensus based – collars should not be prescribed for WAD Grade I. Rest for more than prescribed for WAD Grade I. If prescribed for four days should not be prescribed for WAD WAD Grades II or III, they should be restricted Grades II and III.
to no more than 72 hours.
Basis of QTF recommendationsNo evidence was found concerningindependent benefit of prescribed rest in WAD.
Basis of QTF recommendations QTF recommendations for clinical practice No evidence was found addressing independent Consensus based – There are no indications for benefit of collars in WAD.
surgical intervention in WAD Grades I and II.
Surgery is to be restricted to the rare WAD Soft collars in combination with prescribed rest Grade III with persistent arm pain that does not and analgesics are associated with delayed respond to conservative management or with recovery (pain and ROM) in WAD presenting rapidly progressing neurologic deficit.
within four days of injury.
Soft collars do not restrict ROM in non-injured Basis of QTF recommendations No studies were accepted concerning thebenefit of disc surgery, nerve block or rhizolysis Additional evidence for any Grade or duration in WAD.
A RCT of 196 acute whiplash subjects indicatedthat use of soft collars did not alter the duration Additional evidence or pain in whiplash patients (Gennis P et al., No additional accepted study was identified regarding the benefits of surgery, nerve block In a RCT of 201 acute whiplash subjects it was or rhizolysis in acute management of WAD demonstrated that an ‘act as usual' group had Grades I to III. better outcomes in terms of subjectivesymptoms compared to subjects managed with Basis for changes to QTF recommendations 14 days' sick leave and immobilisation with soft The recommendation has been changed by neck collar (Borchgrevink GE, 1998). A RCT of providing an example of a case which may 220 acute whiplash subjects suggested that benefit from surgery.
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 Basis for changes to QTF recommendationsRecommendation unchanged.
Working Party recommendations
for clinical practice
There are no indications for surgical intervention inalmost all cases of WAD Grades I to III. Surgeryshould be restricted to the rare WAD Grade III withpersistent arm pain that does not respond toconservative management or with rapidly progressingneurological deficit, e.g. cervical radiculopathysupported by appropriate investigations.
Recommendations for clinical practice (continued) Treatment of Whiplash-Associated Disorders Immobilisation - cervical pillows
Additional evidenceNo additional evidence was found concerningthe independent therapeutic effect of spray and Working Party recommendations
for clinical practice
Basis for changes to QTF recommendationsRecommendation unchanged.
Cervical pillows are not recommended.
Injections - steroid injections
QTF recommendations for clinical practiceConsensus based – cervical pillows are notrequired.
Working Party recommendations
Basis of QTF recommendations for clinical practice
No evidence was found addressing thetherapeutic effects of cervical pillows in WAD.
Intra-articular steroid injection cannot berecommended for WAD. Epidural steroid injections Additional evidence should not be used for WAD Grades I or II.
No additional evidence was found.
Occasionally, WAD Grade III with unresolved radicularpain of more than one month might benefit from Basis for changes to QTF recommendations epidural steroid injections.
There is no indication for steroid trigger point Manual and physical therapies
injection in the ‘acute' phase (less than three weeks).
- spray and stretch
Because harmful side effects of repeated steroid usehave been reported, steroid trigger point injectionsshould not be used unless their benefit in WAD is Working Party recommendations
shown in valid RCTs. Intrathecal steroid injections for clinical practice
carry such risk of serious morbidity that they shouldbe avoided in all grades of WAD.
Spray and stretch is not recommended.
QTF recommendations for clinical practice QTF recommendations for clinical practice Consensus based – intra-articular steroid Consensus based – Spray and stretch is not injections are not recommended for WAD.
Epidural steroid injections are notrecommended for WAD Grades I or II.
Basis of QTF recommendations Occasionally, WAD Grade III with unresolved No evidence was found concerning the radicular pain of more than one month might independent therapeutic effect of spray and benefit from epidural steroid injections.
stretch in WAD.
There is no indication for steroid trigger point evidence was found concerning the injection in the ‘acute' phase (less than three effectiveness of the magnetic necklace.
weeks). Because harmful side effects ofrepeated steroid use have been reported, Additional evidence steroid trigger point injections should not be No additional evidence assessing the use of used unless their benefit in WAD is shown in magnetic necklaces in treatment of acute WAD valid RCTs. Intrathecal steroid injections carry Grades I to III was identified.
such risk of serious morbidity that they shouldbe avoided in all Grades of WAD.
Basis for changes to QTF recommendations Basis of QTF recommendations One accepted study showed no benefit of intra- Other interventions – e.g. Pilates,
articular steroid injections in WAD greater thanthree months.
Feldenkrais, Alexander Technique,
massage and homeopathy
No accepted studies were found concerning thebenefit of epidural or intrathecal steroidinjections in WAD. No additional evidence wasfound concerning trigger point steroid injections Working Party recommendations
for clinical practice
Additional evidence Pilates, Feldenkrais, Alexander Technique, massage and No accepted studies were found concerning theacute treatment of WAD Grades I to III with homeopathy are not recommended.
epidural or intrathecal steroid injections orconcerning injection of trigger points. QTF recommendations for clinical practice Basis for changes to QTF recommendations Consensus based – there is no reason for apractitioner to prescribe any of these treatments.
Basis of QTF recommendations Miscellaneous interventions
No evidence was found concerning these - magnetic necklaces
Additional evidence Working Party recommendations
No additional evidence independently assessing for clinical practice
use of any of these modalities in acute WADwas identified. Magnetic necklaces are not recommended.
Basis for changes to QTF recommendationsThe wording of the recommendation waschanged for consistency. The Working Party QTF recommendations for clinical practice could not justify recommending any of these inthe treatment of acute WAD.
Consensus 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 Recommendations for clinical practice (continued) Treatment of Whiplash-Associated Disorders Considered not relevant to treatment of acute WAD Grades I, II or III Injections
Injections
- sterile water injections
- local anaesthetic nerve blocks
Working Party recommendations
Working Party recommendations
for clinical practice
for clinical practice
Not included. Not relevant to management of acute Not included. Not relevant to management of acute WAD Grades I to III.
WAD Grades I to III.
QTF recommendations for clinical practice QTF recommendations for clinical practice Consensus based – sterile water subcutaneous Not included.
trigger point injections can be used for WADGrade II where trigger points are present as an Basis of QTF recommendations optional adjunct to activating interventions with Not included.
emphasis on return to usual activities.
Additional evidence Basis of QTF recommendations Not included. Not relevant to management of This recommendation was based on one acute WAD Grades I to III.
accepted RCT from a WAD Grade II patientwith neck and shoulder pain four to six years Basis of change to QTF recommendations after injury that suggested a sustained smallbenefit of subcutaneous sterile water injections. Not included. Not relevant to management ofacute WAD Grades I to III.
Additional evidenceNot included. Not relevant to management ofacute WAD Grades I to III.
Basis for changes to QTF recommendations Not included. Not relevant to management ofacute WAD Grade I to III.
The Working Party Thanks go the Working Party who guided this project.
In establishing this Working Party the MAA was and chiropractors, manage much of the health aware that primary care health professionals, burden from Whiplash-Associated Disorders.
especially general practitioners, physiotherapists Senior Rehabilitation Advisor Allianz General InsuranceInsurance Council of Australia Dr Stephen Buckley (Chair) Rehabilitation Physician Australasian Faculty of Rehabilitation Medicine Motor Accidents Council A/Prof. Dr Ian Cameron* Rehabilitation Physician Faculty of Medicine, University of Sydney Dr Louise Crowle*/ NE&A Pty Ltd/PWC Dr Michael Eagleton Australasian Association of Surgeons Occupational and NE&A Pty Ltd/PWC Public Health Physician General Practitioner School of Community Medicine, University of NSW, nominee of theRoyal Australian College of General Practitioners (NSW Faculty) Mary Hawkins/Anna Bray Workplace Injury WorkCover Authority NSW Management Branch Law Society of New South Wales Chiropractors' Association of A/Prof. Gwendolen Jull* Specialist Manipulative Faculty of Health Sciences, The University of Queensland, nominee of the Motor Accidents Insurance Commission (Qld) Australian Physiotherapy Association (NSW Branch) Principal Advisor, Rehabilitation Motor Accidents Authority Manager, Strategic Planning NRMA Insurance Council of Australia The Working Party (continued) Australian Physiotherapy Association (NSW Branch) Consumer Representative Consumer Representative (one meeting only) Dr Simon Willcock General Practitioner Department of General Practice, University of Sydney, nominee of the Royal Australian College of General Practitioners (NSW Faculty) Consultant Physician in Royal Prince Alfred Hospital, Rehabilitation and nominee of the Australian Medical Musculoskeletal medicine and Registered Osteopath (UK) * Also member of the Technical Group The MAA is also grateful to those who providedcomment on the draft guidelines, some ofwhich was quite critical, and led to a significantre-working of the clinical guidelines. The organisations and individuals from whomcomment was received are listed in theTechnical Report.
Thanks also to three expert reviewers whomade final comments.
Marc WhiteCentre for the Study of Curriculum and InstructionFaculty of EducationUniversity of British ColumbiaVancouverBritish Columbia Professor Bogdan RadanovDepartment of PsychiatryUniversity of BerneBerneSwitzerland Professor Peter BrooksRheumatologistExecutive Dean of Health SciencesUniversity of QueenslandAustralia Adverse prognostic indicators
Multi-disciplinary pain team
Factors that have been associated with A group of health care providers capable of adverse outcomes. assessing and treating the physical,psychosocial, medical, vocational and social aspects of patients with chronic pain. The Commercially made contoured pillows.
health care team should hold regular meetingsconcerning individual treatment outcomes and evaluate overall program effectiveness.
Majority view of all members of the Working Party. The basis for recommendations in theabsence of evidence.
Management that includes simultaneousapplication of treatment modalities including relaxation training, manual and physicaltherapies, exercise, postural training and May be either a direction to increase activity or a prescription for a specific set ofexercises.
Motor vehicle accident.
To prevent motion of the neck usually by application of a cervical collar.
Motor vehicle collision.
A technique of treatment applied to joints forthe relief of pain and improvement of motion.
Non-steroidal anti-inflammatory drug(s).
It is a single high velocity, low amplitude movement applied passively to the jointtowards the limit of its available range.
Those electrotherapeutic agents that areapplied for such purposes as the relief of pain Manual and physical therapies
and assisting the resolution of the Methods of treatment (e.g. manipulative and inflammatory response. They are administered exercise therapy) used in the rehabilitation of passively to the patient.
persons with musculoskeletal disorders. They are non-invasive, non-pharmaceutical methodsof treatment. Pulsed electromagnetic treatment.
Miscellaneous interventions not
Postural advice
Specific instructions on posture.
A set of complementary health treatments identified in the QTF guidelines not addressedseparately.
Recommendation of specific activity, e.g.
walking.
A technique of treatment applied to joints forthe relief of pain and improvement of motion.
Recommendation of ‘rest' that may include Mobilisation is the passive application of avoidance of some activites of daily living.
repetitive, rhythmical, low velocity, smallamplitude movements to the joint within or at the end of range.
Quebec Task Force.
Glossary (continued) Symptoms caused by irritation of the A passive, longitudinal force of a vertebral segment that can be applied manually ormechanically with the aim of inducing subtle vertebral distraction for duration of the Randomised controlled trial.
Relaxation
Whiplash-Associated Disorders (WAD)
Techniques used to reduce muscle tension Whiplash is an acceleration-deceleration and anxiety.
mechanism of energy transfer to the neck.
It may result from ".motor vehicle collisions." The impact may result in bony orsoft tissue injuries, which in turn may lead to Range of movement.
a variety of clinical manifestations.
Soft collars
Foam neck supports.
Modification of work duties and/or environment to accommodate an injuredworker.
Specialised tests that are not routinelyperformed as part of physical examination Yellow flags
and that often require specialised testing Condition in which adverse prognostic indicators have been identified. ‘Yellow flags' Specialised imaging techniques
is a term developed in the area ofmusculoskeletal medicine to describe adverse All radiological techniques except plain film prognostic indicators. The presence of yellow flag factors indicates the potential need for Spray and stretch
more complex management.
Techniques where a coolant spray is appliedto a painful area as a precursor to stretching.
Transcutaneous electrical nerve stimulation isa non-invasive low frequency electricalstimulation, which is applied through the skinwith the aim of introducing an afferentbarrage to decrease the perception of pain.
Scientific Monograph of the QTF on Whiplash-Associated Disorders, Redefining "Whiplash" andIts Management, Spine, 1995, Supplement Vol 20 Num 85.
See for example Teasall, RW et al., Limitations of the QTF on Whiplash-Associated Disorders,AAPM&R 61st Annual Assembly and 13th World Congress of the International Federation ofPhysical Medicine and Rehabilitation, November 1999; and Freeman M, Croft A, and Rossignol A,"Whiplash-associated Disorders: Redefining whiplash and its management" by the QTF. Spine;1998, 23(9): 1043–1049.
See for example Cassidy, D et al., The QTF on Whiplash-Associated Disorders – Impact andUpdate, AAPM&R 61st Annual Assembly and 13th World Congress of the International Federationof Physical Medicine and Rehabilitation, November 1999.
‘Yellow flags' is a term developed in the area of musculoskeletal medicine to describe adverseprognostic indicators. The identification of yellow flags indicates the potential need for morecomplex management.
To find out more about practitioner registration visit the NSW Department of Health web site:http://www.health.nsw.gov.au. Scientific Monograph of the QTF on Whiplash-Associated Disorders, Redefining "Whiplash" andIts Management, Spine, 1995, Supplement Vol 20 Num 85. Although the term ‘whiplash injury' was included in the QTF definition, this has been excludedas it is not concise and confuses cause and effect.
Arm pain on its own is not sufficient for a diagnosis of WAD Grade III.
National Health and Medical Research Council, A guide to the development, implementation andevaluation of clinical practice guidelines, Ausinfo, Canberra, 1999.
Now published: Cassidy DJ et al., Effect of Eliminating Compensation for Pain and Suffering onthe Outcomes of Insurance Claims for Whiplash Injury, New England Journal of Medicine, April20, 2000, Vol. 342, No 16, p 1179–1186.
Wrightson P, Gronwall D, Time off work and symptoms after minor head injury, Injury 1981;12:445–54.
NHMRC, Acute pain Management: information for general practitioners, Commonwealth ofAustralia, 1999.
For more information If you have queries or need copies of this publication, contact:Motor Accidents AuthorityLevel 22580 George Street, Sydney NSW 2000Phone: 1300 137 131 Fax: 1300 137 707 ISBN 1 876958 02 2 Web site: www.maa.nsw.gov.aue-mail: [email protected] Claims Advisory Service 1300 656 919

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