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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
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
Most current whiplash treatments were deemed lacking scientific
validation:
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"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."
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.
DC
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