Quebec Task Force Rewrites Whiplash Protocols

Neck pain is to the automobile what low back pain is to the workplace.

The health costs of whiplash-associated disorders (WADs), while not as high as the cost of low back pain, affects over 120,000 Americans each year. North of the border, the province of Quebec in 1987 payed out over $18 million Canadian health care dollars for whiplash injuries. That significant expenditure moved the Quebec Automobile Insurance Society to fund a major study on whiplash-associated disorders.

The Society approached Walter Spitzer, MD, MPH, FRCPC, professor of medicine at McGill University, to gather an international team of whiplash experts. Dr. Spitzer formed the Quebec Task Force on Whiplash Associated Disorders, an 18-member group that included chiropractic researcher J. David Cassidy, DC, PhD, FCCSC. Their monogram was published in the April 15, 1995 supplement of the Spine journal (to order a copy, call 800-638-3030).

The literature review was particularly rigorous, lasting nearly two years and encompassing 10,382 research papers on the treatment of whiplash. Of the 10,382 studies only 1,204 met the preliminary screening criteria, many because they were case histories without any validation of treatment efficacy. From there, the panel whittled down the studies to a select core group of 294. These studies were then rated for relevance and scientific merit. Only 62 of the 294 (21 percent) made the final cut and were deemed acceptable to the task force. This lack of acceptable research would ultimately leave many forms of whiplash treatment without any evidence of efficacy.

One of the most important developments to come out of the work of the task force is a classification system for WAD complaints. This ultimately facilitates better application of treatment based upon clinical findings.

Proposed Clinical Classifications of Whiplash Associated Disorders (WAD)
0	No complaint about the neck-No physical sign(s)
I	Neck complaint of pain, stiffness or tenderness only-No physical sign(s)
II	Neck complaint and musculoskeletal sign(s)
III	Neck complaint and neurological sign(s)
IV	Neck complaint and fracture or dislocation

Summary of the Findings Quebec Task Force
IMMOBILIZATION
Collars	No research.	No more than 72 hours.
Bed Rest	No research.	No more than 4 days.
Cervical Pillows	No research.	Not required.
ACTIVATION
Manipulation	Two studies.	Short regimen can be used.
Mobilization	Combined studies.	Regimen can be used.
Exercise	Combined studies.	Range of motions exercises suggested.
Postural Advice	Combined studies.	Can be given.
Spray & Stretch	No research.	Not recommended.
Traction	Combined studies.	Regimen can be combined with mobilization.
PASSIVE MODALITIES/ELECTROTHERAPIES
TENS	No research.	Optional activation adjunct.
PEMT	Two studies.	Not recommended.
Electrical Stimulation, Ultrasound, Laser, Short Wave Diathermy, Heat, Ice, Massage	No Research.	Optional activation adjuncts.
SURGICAL TREATMENT
Surgery	No research.	Very restricted use.
INJECTIONS
Steroid Injections	One study.	Not recommended except epidural.
Sterile Water Injections	One study.	Optional adjunct to activation
PHARMACOLOGY
Narcotic Analgesics	No Research.	Not recommended.
Psychopharmacologics	No research.	Not Recommended.
Analgesics or NSAIDS	Combined studies.	Up to 3 weeks for pain.
MISCELLANEOUS INTERVENTIONS (formally prescribed)
Prescribed Function (neck school, work alternatives, relaxation techniques)	One study.	Recommended.
Acupuncture	One study.	Not recommended.
OTHER INTERVENTIONS (not formally prescribed)
Magnetic Necklace	One study.	Not recommended.

Most current whiplash treatments were deemed lacking scientific validation:

"Most therapeutic interventions currently used in patients with WAD have not been evaluated in a scientifically rigorous manner. These unproven therapies include cervical pillows, postural alignment training, acupuncture, spray and stretch, transcutaneous electrical stimulation, ultrasound, laser, short-wave diathermy, heat, ice, massage, epidural or intrathecal injections, muscle relaxants, and psychosocial interventions."

The evidence of efficacy of whiplash treatments is meager:

"Treatments evaluated in a scientifically rigorous manner show little or no evidence of efficacy. There is little or no evidence of efficacy for soft cervical collars, corticosteroid injections of the zygapophysial joints, pulsed electromagnetic treatment, magnetic necklace, and subcutaneous sterile water injection. Use of soft cervical collars beyond the first 72 hours probably prolongs disability with WAD."

Manipulation, coupled with other treatment(s) and time limitations, was recognized as effective:

"Interventions that promote activity such as mobilization, manipulation, and exercises in combination with analgesics or nonsteroidal anti-inflammatory agents are effective on a time-limited basis."

For the chiropractic profession, the task force findings may not be surprising. The consensus recommendation for short-term spinal manipulation was based on two studies and specified:

"Practitioners of manipulative therapy should emphasize early return to usual activity and the promotion of mobility. The task force consensus is that manipulative treatments by trained persons for the relief of pain and facilitating early mobility can be used in WAD. All such treatments should be accompanied by reassurance about the good prognosis of WAD, should discourage extended dependence on the health professional, and promote resumption of continuation of usual activities and work. Long-term, repeated manipulation without multidisciplinary evaluation is not justified."

The authors of the two studies recommend that more randomized controlled trials be conducted to "assess the short and long-term regimen of manipulative therapy."