Dynamic Chiropractic - June 19, 1995, Volume 13, Issue 13|
Quebec Task Force Rewrites Whiplash Protocols
Validation for Efficacy of Treatment Sadly Lacking"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
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
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:
Manipulation, coupled with other treatment(s) and time limitations, was recognized as effective:
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:
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."
IMMOBILIZATIONCollars No research. No more than 72 hours.
Bed Rest No research. No more than 4 days. Cervical Pillows No research. Not required.
ACTIVATIONManipulation 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/ELECTROTHERAPIESTENS 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.
Surgery No research. Very restricted use.
INJECTIONSSteroid Injections One study. Not recommended except epidural.
Sterile Water Injections
One study. Optional adjunct to activation
No Research. Not recommended.
No research. Not Recommended.
Analgesics or NSAIDS
Combined studies. Up to 3 weeks for pain.MISCELLANEOUS INTERVENTIONS
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.DC