Docstoc

Whiplash Associated Disorders final

Document Sample
Whiplash Associated Disorders final Powered By Docstoc
					The Early Physiotherapy Management
  of Whiplash Associated Disorders




               MScPT Major Project

                    Lynn Lam
                  Jason Melnikel
                   Bonnie Trang




          Department of Physical Therapy
         Faculty of Rehabilitation Medicine
               University of Alberta




                                              1
                                                  TABLE OF CONTENTS


Section                                                                                                               Page

ABSTRACT....................................................................................................................3

INTRODUCTION
     Definition and Description of Whiplash Associated Disorders..........................4
     Natural Course of Recovery and Prognosis ........................................................5
     Epidemiology......................................................................................................6
     Role of Physiotherapy.........................................................................................7
     The Nose Creek Sports Physical Therapy Protocol............................................8

METHODS
    Design .................................................................................................................9
    Subjects ...............................................................................................................9
    Data Collection .................................................................................................10
    Article Appraisal...............................................................................................11
    Data Analysis ....................................................................................................12

RESULTS
     Search Results...................................................................................................12
     Methodology Quality ........................................................................................13
     Early Management ...........................................................................................14
     Effectiveness of Interventions...........................................................................15
     Role of Education and Patient Educational Materials ......................................17

DISCUSSION ..............................................................................................................18
     The Nose Creek Protocol .................................................................................20
     Limitations of the Study ...................................................................................21
     Outcome of the Project ....................................................................................21

REFERENCES .............................................................................................................23

APPENDIX 1: The Nose Creek Sports Physical Therapy Protocol .............................26
APPENDIX 2: EMBASE and Medline Search Algorithm...........................................27
APPENDIX 3: AMSTAR Appraisal Tool....................................................................32
APPENDIX 4: PEDro Scale .........................................................................................34
APPENDIX 5: Data Extraction Table of Systematic Reviews.....................................35
APPENDIX 6: Data Extraction Table of Randomized Controlled Trials ....................42




                                                                                                                                2
Abstract

Background: Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck

typically diagnosed in a large percentage of the motor vehicle accident population. WAD I and

II injuries include neck pain and stiffness with or without physical signs excluding neurological

signs and fractures. Because of the large role physiotherapy plays in the recovery of WAD, the

therapists at Nose Creek Sport Physical Therapy in Calgary, Alberta, Canada, have developed an

early intervention (first 2 weeks) protocol for WAD I and WAD II care and management. This

protocol is based largely on clinical expertise. To facilitate evidenced-based practice, an up to

date critical appraisal of the literature for early WAD intervention is required.

Purpose: The purpose of this study was to merge clinical opinion/expertise with research to

ensure best evidence based practice. The Nose Creek protocol was evaluated against the

available literature on early management, the type of intervention, and educational prognostic

factors and recommendations will be made for revisions to the protocol.

Methods: A scoping literature review for randomized controlled trials and systematic reviews

was performed through The Cochrane Library, Medline, EMBASE, CINAHL, Pedro and

Dynamed. The limits used, where applicable, were adults (18+), English papers and articles

published in the past 20 years. The search terms used were compiled in consultation with a

research librarian. The results of the searches were imported into RefWorks where they were

pooled and filtered for exact and close duplicates and scanned for relevance by title and abstract.

From the remaining articles, three independent reviewers assessed methodological quality and

extracted data.

Results: Eighteen studies representing thirteen systematic reviews and five randomized

controlled trials (RCT) were selected for inclusion. Of the thirteen systematic reviews, eight



                                                                                                    3
studies were graded as moderate quality and five studies were graded as high quality studies.

Regarding the five RCTs, four were appraised as moderate quality and one was graded as high

quality. The methodological quality and outcomes of all the studies were summarized in tables.

Conclusions: There is moderate evidence to support early physical therapy for decreasing pain

and time off work and moderate to strong evidence to suggest that general exercise and returning

to regular activities has the greatest benefit on recovery. There is conflicting evidence on the

effectiveness of active exercises for the cervical spine. The evidence is highly limited and

conflicting on the effectiveness of passive treatments and when determining whether one mode is

more effective than another. However, there is moderate to strong evidence that soft collars

should be avoided in patients with WAD I or WAD II. As well, this study found conflicting

evidence on whether educational techniques have short term symptom relief and/or long term

benefits in patients with WAD I or II and there appears to be no significant difference between

educational information delivered to the patient orally or written in a pamphlet.



Introduction


Definition and Description of Whiplash Associated Disorders (WAD)

       As stated by the Quebec Task Force: “Whiplash is an acceleration-deceleration

mechanism of energy transfer to the neck.      It may result from rear end or side impact motor

vehicle collisions, but can also occur during diving or other mishaps. The impact may result in

bony or soft tissue injuries (whiplash injury), which in turn may lead to a variety of clinical

manifestations called whiplash associated disorders.”20

       The specific mechanism of injury for a rear-end impact collision is outlined as follows: a

person’s trunk is thrust forward while it concurrently contacts the forward moving seat.19 This


                                                                                                 4
causes a transient S-shaped posture of the C-spine, which results in the C-spine to undergo

aphysiological movement of extension in the lower segment and flexion in the upper segment.19

The direct consequence of the event is significant loading and forces to the cervical spine.19 This

is usually followed by a rapid release that forces the head and neck forward, which results in

further damage. Research suggests that this biomechanical event can lead to injuries to the

anterior longitudinal ligaments and transverse ligament of the ala, pinching and impacting the

cervical zygapophyseal joints (believed to be involved in the pain generator in WAD), and can

accelerate normal age-related disc degeneration which may contribute to chronic neck pain after

the injury.19

        Whiplash associated disorder is divided into four classes outlined by The Quebec Task

Force classification system.20 Persons would be classified under WAD I if he/she had neck

complaints, with stiffness or tenderness in the region of the neck, and no physical signs of

injury.8,20 In addition to neck complaints, WAD II includes physical signs such as point

tenderness, reduced range of motion or trouble turning the head, WAD III would present with

neurological signs such as changes in reflexes or weakness, and WAD IV with a fracture or

dislocation of the neck.8,20 The focus for this project is on the patient population affected by

WAD I & WAD II.



Natural Course of Recovery and Prognosis

        Although the evidence on the natural course of recovery is widely variable, it has been

estimated that between 9% and 26% of patients were still absent from work at six months post

injury.20 The majority of evidence indicates that recovery in adults with WAD is prolonged, with

about 50% of patients reporting neck pain symptoms one year after the injury.5 In fact, up to



                                                                                                 5
seven years post injury, those who had a history of WAD symptoms can still be at risk for neck

pain.2

         A systematic review on prognostic factors influencing WAD recovery indicated that

greater initial symptom severity, post-injury psychological distress and passive coping styles

were factors for poor prognosis.5 Similarly, another systematic review found that initial

symptoms like high levels of pain, limited range of motion of the neck, and psychological factors

demonstrated moderate influence on recovery.15 Most collision specific factors like position of

the occupant’s head, awareness of the imminent collision, and direction of the collision, were

risk factors for neck injury; but these were not prognostic for recovery in WAD.5 There is

conflicting evidence on whether age, gender, litigation or socio-economic status influences

recovery.7,15

         Knowledge of the natural course and prognosis of WAD are vital as patients, their

families, and physical therapists are generally interested in two key questions: Will the pain and

associated symptoms go away and in what time frame?5 Having knowledge of the course of

recovery and prognostic factors enables physical therapists to suggest treatment interventions

and possible lifestyle changes for the patient.



Epidemiology

         Whiplash can account for as much as 83% of injuries in motor vehicle collisions.6 It has

been reported in Saskatchewan, Canada, that the incidence rate for whiplash was 834 per

100,000 persons in 1994, and 598 per 100,000 persons in 1995.6 For British Columbia, Canada,

whiplash claims accounted for 57.5% of all motor vehicle collision injuries and an incidence rate

of 907 claims per 100,000 persons in 1999.1



                                                                                                6
       Physiotherapy plays a large role in the recovery of WAD, dominating 46% of patient

health care costs for British Columbia. This would be compared to 24% for medical, 13% for

chiropractic and 17% for massage therapy.1 Legal expenses, pharmaceutical expenses and

indirect costs, such as patient time missed from work, were not included in these statistics and

these factors could lead to a significant amount of resources spent on WAD. With that being

said, a large percentage of the motor vehicle collision population may have whiplash-associated

disorders, making the costs for these injuries formidable.       It is therefore necessary for

physiotherapists to have strong evidence based best practice to provide efficient treatment

programs.



Role of Physiotherapy

       Physiotherapists help patients manage whiplash by first taking a thorough subjective

history of the client to determine mechanism of injury, clear any potential “red flag” problems,

determine the extent of patients’ subjective limitations, and establish patient goals. Following

the history, an objective assessment must be performed to determine anatomical and functional

impairments.

       Due to the highly variable natural course of recovery of WAD, recent trends have

recognized physiotherapy as an effective treatment for WAD.9 Whiplash Associated Disorder

can present similar to generic neck injury acquired from other activities, and its course of

recovery has also been found to be similar to the course of recovery of neck pain in the general

population and the working population.3,4 Physical therapists can provide intervention choices

with progression in levels of activity because WAD is thought to be essentially a soft tissue

sprain or strain as a result of a motor vehicle collision. This is accomplished by understanding



                                                                                              7
the factors affecting recovery of WAD to guide treatment, assisting with setting realistic goals,

and optimizing recovery to increase quality of life.



The Nose Creek Sport Physical Therapy Protocol

       The physical therapy team at Nose Creek Sport Physical Therapy in Calgary, Alberta,

Canada, has developed an early intervention protocol for WAD I and WAD II care and

management (Appendix 1).10 The team developed this program to initiate and promote patient

recovery in a clinically standardized best-practice manner with the intention to reduce recovery

time. It is used by the Nose Creek therapists for treatment and development of a home program

for patients and is also being distributed to local physicians to use at initial patient contact.

Junior therapists at the clinic are also instructed to follow the protocol as a means of quality

control within the clinic between therapists. This program is based on therapist opinion, clinical

experience, and a non-systematic literature search. This protocol focuses on three factors that

influence early recovery: (1) time to begin therapy, (2) interventions, and (3) educational

prognostic factors. Time to begin physiotherapy is addressed with the patient being encouraged

to see a physical therapist early (within the first two weeks of injury) for initial assessment,

treatment, and education on self-management. The interventions included in the protocol are ice,

heat, range of motion exercises, and walking. The written protocol given to the patient is used as

a home exercise program, educational intervention, and to address psychosocial prognostic

factors through reassurance of a decrease in symptoms and accelerated return to activity.

       The protocol begins with a treatment of ice applied to the cervical region for the first 3-4

days post injury, 3-6 times per day for 15 minutes. Cryotherapy is used to control acute

inflammatory processes related to soft tissue injury. Heat treatment is then used after 3-4 days



                                                                                                 8
post injury in alteration with ice treatment. The best type of heat is moist heat: hot bath/shower

or heating pads 2-3 times per day for 15-20 minutes. This thermal intervention is used to reduce

patient symptoms. Range of motion exercises should be performed slow and gentle in pain free

range 3 times per day. The exercises include: neck flexion (10 reps), neck rotation (left and

right, 10 reps each), and trunk rotation (left and right, 10 reps each). The ROM exercises are

suggested to assist with recovery. The last proposed intervention is an early return to activity,

which is recommended as a 10-30 minute walk, 2-3 times per day. Walking will help with

recovery via increased blood flow, reducing stiffness, and maintaining mobility.



Methods

Design

         A scoping literature review was conducted to look at the effectiveness of an early WAD

management protocol. The knowledge gained from the literature was used to evaluate the

protocol proposed by Nose Creek Sport Physical Therapy. The article selection and assessment

were conducted independent of Nose Creek Sport Physical Therapy.



Subjects

         The literature review included articles that discussed WAD I and II injuries in male and

female adults (18 years and older); who had been involved in a motor vehicle collision and were

in the acute stage of injury (i.e. within the first 2 weeks post-collision), and being treated by

physical therapy.



Data Collection



                                                                                                9
       A literature search was performed through The Cochrane Library, PEDro, Medline,

EMBASE, CINAHL, and Dynamed. The literature search was based on the intervention, timing

and prognostic factors addressed in The Nose Creek Sport Physical Therapy protocol. The

specific set of search terms for EMBASE and Medline were determined in consultation with a

librarian for each database (see Appendix 2). In general, early physical therapy management was

explored using the search terms: early management, physical therapy, acute, whiplash injuries,

treatment, outcome, and effectiveness. The general search terms for interventions included:

whiplash injuries, physical therapy, neck flexion, neck rotation, range of motion, cold, ice, cold

temperature, cold treatment, heat, hot temperature, heat treatment, and walking. Effectiveness of

the role of education and patient information materials for management and prognosis of WAD

recovery were also integrated into the literature search. These search terms included: education,

effectiveness, pamphlet, prognosis, and patient education.

       The limits used, where applicable, were adults (18+), English papers and articles

published in the past 20 years. Only articles available on-line were collected; all articles were

subsequently exported to RefWorks where duplicates were removed. The articles were then

independently screened by the reviewers for population, appropriateness, and applicability. The

reviewers were blind to all article information except for title, abstract, and authors.

       Systematic review papers and randomized controlled trials (RCT) that met the above

stated inclusion criteria were appraised.       The appraised RCTs were subsequently cross-

referenced with the RCTs used in the appraised systematic reviews. Duplicates were compared

methodologically via standardized appraisal forms (discussed below). If the quality comparison

was similar between our appraisal of the primary RCT and the systematic reviewers’ appraisal,




                                                                                               10
the individual RCTs were not included in this study. If there was a significant discrepancy

between comparisons, those RCTs were included in this study.



Article Appraisal

       The authors, L.L., J.M., and B.T., assessed the articles using validated appraisal tools to

ensure reliability for methodological quality.      The authors have completed two accredited

university courses on article critical appraisal. Systematic reviews were assessed using the

AMSTAR appraisal tool17 (Appendix 2).          The AMSTAR, which consists of 11-items, has

satisfactory inter-observer agreement, reliability, and construct validity14. For each item that is

satisfied in the scale, 1 point is added to the total score out of 11. In addition, this scale has

shown to be relevant to physiotherapy as it has been used in a systematic review examining the

therapeutic management of upper-limb dysfunction in children with congenital hemiplegia.14

       Randomized controlled trials (RCT) were assessed using the PEDro Scale18 (Appendix

3), which consists of 11-items that rate for methodological quality. The reliability for total

PEDro scores would be considered moderate with inter-rater reliability correlation coefficient of

0.54 and 95% confidence interval of 0.39-0.71.11 Nevertheless, the scale does provide sufficient

reliability for use in systematic reviews of RCTs in physical therapy.17 Each item that is satisfied

in the scale (except for item 1, which relates to external validity) contributes to one point, giving

a total possible score out of 10.

       Reviews were labeled as low quality if given a score of 0 to 4 out of 11, moderate quality

if given a score of 5 to 7 out of 11, and high quality if given a score of 8 to 11 out of 11.

Randomized controlled trials were labeled as low quality if given a score of 0 to 4 out of 10,




                                                                                                  11
moderate quality if given a score of 5 to 7 out of 10, and high quality if given a score of 8 to 10

out of 10.



Data Analysis

       The three authors independently reviewed all the appraised articles, regardless of the

quality score received. Interpretation of the appraisal ratings were determined by discussion and

majority vote. The results were summarized in a data extraction table (Appendix 4 and 5). The

table includes the article author(s), design, appraisal score, subjects, intervention/dosage,

outcome measures, and results. Design indicates the type of study: systematic review or

randomized control trial. The appraisal score is the individual score the article received from the

appraisal tool. Parameters such as the population studied, intervention (including dosage),

outcome measures, and results were extracted after a thorough review of the article. Outcome

measures were derived from the papers that were reviewed.



Results

Search Results

       The results of our electronic database search are detailed in Figure 1. The initial search

resulted in 2,157 articles from Medline (758), EMBASE (596), CINAHL (265), The Cochrane

Library (457), PEDro (80) and Dynamed (1). After duplicates were removed and scanning was

completed for relevance, thirty-one articles remained which included thirteen systematic reviews

and eighteen RCTs. In addition, thirteen RCTs examined in the systematic reviews were

excluded because the methodological quality ratings were similar to those determined by the




                                                                                                12
authors of this study. Five RCTs were not found within the thirteen systematic reviews. As a

result, thirteen systematic reviews and five RCTs were selected for inclusion.


                                   Citations from electronic database searches (n = 2157)

      Excluded after screening
          titles (n = 1918)
                                           Abstracts retrieved for screening (n = 239)

        Excluded after screening
          abstracts (n = 208)
                                                 Full text retrieved for appraisal
                                              (systematic reviews = 13, RCTs = 18)
           RCTs excluded after
           comparison (n = 13)
                                          Studies included in data extraction process
                                             (systematic reviews = 13, RCTs = 5)



Figure 1           Flow diagram of search results



Methodological Quality

        The methodological quality score of the included studies are summarized in Tables 1 and

2. Of the thirteen systematic reviews, eight studies were graded as moderate quality (scoring

between 5 to 7 out of 11) and five studies were graded as high quality studies (scoring between 8

to 11 out of 11). Regarding the five RCTs, four were appraised as moderate quality (scoring

between 5 to 7 out of 10) and one was graded as high quality (scoring 10/10).



Table 1: Quality assessment scores for included randomized controlled trials

                                                          PEDro Criteria
                                                                                                    Total
   Authors, year     Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 (/11)

Dehner et al, 2009 NA       Y      Y      Y       N      N      N      Y      Y      N      Y               6

                                                                                                            13
Gonzalez-Inglesias
et al, 2009        NA      Y      Y      Y      Y      Y       Y      Y      Y      Y      Y               10
Kongsted et al, 2008 NA    Y      Y      Y      N      N       N      N      Y      N      Y                5
Olivera et al, 2010 NA     Y      N      Y      N      N       N      Y      Y      Y      N                5
Scholten-Peeters,
2007                NA     Y      Y      N      Y      N       N      Y      Y      Y      Y                7




Table 2: Quality assessment scores for included systematic reviews

                                                       AMSTAR Criteria
                                                                                                   Total
   Authors, year    Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 (/11)
Conlin et al, 2005 Y       Y      Y      N      N      Y      Y       Y      Y      N      N                7
Drescher et al, 2008 Y     Y      Y      N      N      Y      Y       Y      Y      N      N                7
Haines et al, 2010 Y       Y      Y      Y      Y      Y      Y       Y      Y      Y      Y               11
Hurwitz et al, 2008 Y      Y      N      N      N      Y      N       Y      Y      Y      Y                7
Kay et al, 2009     Y      Y      Y      Y      Y      Y      Y       Y      Y      Y      Y               11
Kroeling et al, 2005 Y     Y      Y      Y      N      Y      Y       Y      Y      N      Y                8
Lundmark and
Persson, 2006        Y     N      Y      Y      N      Y      Y       Y      N      N      N                6

Mercer et al, 2007 N       N      Y      N      Y      N      Y       Y      Y      N      N                5
McClune et al,
2002               Y       Y      Y      Y       N     N      N       Y      N      N      N                5

Peeters et al, 2001 Y      Y      Y      Y      N      Y      Y       Y      N      Y      N                8

Sarig-Bahat, 2003 Y        N      N      N      Y      Y      Y       Y      N      Y      N                6
Seferiadis et al,
2004              Y        Y      Y      N      N      N      Y       Y      Y      Y      N                7
Verhagen et al,
2010              Y        Y      Y      Y      Y      Y      Y       Y      Y      Y      Y               11




Early Management

        There is a general consensus between five systematic reviews (all of moderate quality)

that early physical therapy for the treatment of acute WAD I and II results in better outcomes.

Physical therapy consisting of education, postural control and gentle small range and amplitude

rotational movement of the neck and commencing within 4 days (96 hours) was shown to

significantly decrease pain and encourage recovery.33,36 One review also concluded that early

                                                                                                           14
physical activity decreased the number of days off work.38 There is conflicting evidence from

two reviews22,38 regarding whether early active management increases cervical range of motion.



Effectiveness of Interventions

Active interventions

       Articles investigating active interventions included postural and neck stabilization

exercises, proprioception exercises, active range of motion, and general physical activity for the

treatment of WAD I and WAD II. Two moderate quality systematic reviews suggested that there

is no significant evidence found to support the use of postural and neck stabilization exercises24

and there is no significant improvement of pain, physical parameters (e.g. ROM, posture, etc.) or

function at six months for patients with additional exercises to improve kinesthetic sensibility

and neck muscle coordination.22 However, a moderate quality systematic review concluded that

there is moderate evidence to support use of postural exercises for decreasing pain and time off

work.24 In addition, a high quality systematic review28 found limited evidence that eye-fixation,

used to restore coordinated movement or cervicoencephalic kinaesthesia utilizing visual training

techniques, along with proprioception exercises of the cervical spine shows benefits for pain,

function, and perceived effect for acute and sub-acute WAD. The same high quality systematic

review28 stated that there is limited evidence for the benefit of active range of motion on reducing

pain in acute WAD.

       A moderate quality27 and a high quality systematic review39 found that there is

inconsistent evidence suggesting that active exercises to mobilize the neck were positively linked

to a more favorable prognosis in the short or long term when compared to passive treatment

including exercise. However, there is general consensus from the systematic reviews that active



                                                                                                 15
exercises and returning to normal activity provides positive benefits in the recovery of whiplash

injuries. Active exercises and “act as usual” are shown to decrease pain, encourage recovery,

decrease the number of days off work and decrease disability.27,31,33,35,36,38,39 Activity was shown

to be significantly better than immobilization or no treatment for decreasing pain, decreasing

time to return to work and increasing ROM.35,39

Passive interventions

       Articles examining passive modality interventions included a high quality systematic

review30 looking at whether electrotherapy relieves pain or improves function in adults with

mechanical neck disorders. This review suggested that there is limited evidence for the use

electrical muscle stimulation, permanent magnets, and high frequency pulsed electromagnetic

therapy (PEMT), conflicting evidence for the use of TENS, and no detectable difference in the

use of galvanic and modulated galvanic current.30 A randomized control trial of moderate

quality looked at other passive modalities like moist heat, classic massage, along with

electrotherapy compared to an active physical therapy group for the treatment of WAD II.23 The

active physical therapy group showed a significantly greater median improvement in pain than

the passive physical therapy.23 However, these two physical therapy groups did not differ

significantly in period of disability.23 One moderate quality systematic review27 and one high

quality systematic review28 concluded that passive modalities (when also included in a home

exercise program) are not associated with reduction of pain when compared to active exercise

and manual therapy. Furthermore, passive modalities are found not to be more effective than

placebo or no treatment for relieving symptoms.39

            There is conflicting evidence on whether manual therapy (e.g. manipulations and

mobilization of the spine) reduces pain. One systematic review27 of moderate quality reported



                                                                                                 16
there is lack of evidence to support cervical spine, thoracic spine manipulations or traction to

reduce symptoms. The systematic review found that mobilizations were more effective in the

short term for pain reduction when compared to the use of collars, passive modalities, and

advice, but were as effective as staying active.27 As well, another systematic review reported that

there is moderate evidence that manual mobilizations should be conducted to decrease pain.33 A

RCT of high quality25 that looked at the effects of Kinesio Taping over the posterior cervical

extensor muscles with paper-off tension to reduce pain and increase range of motion of the

cervical spine concluded that there were significant improvements in both outcome measures.

However, there changes were small and the results did not surpass the minimal clinically

important difference.25

Immobilization

       Immobilization of the cervical spine for the treatment of patients with WAD I or WAD II

was investigated by the use of soft collars in the reviews included in this study. There is a

general agreement between six systematic reviews22,24,27,31,33,35, all of moderate quality, that soft

collars do not provide any benefit to recovery for patients with whiplash injuries.             One

systematic review22 concluded that patients who did not use a soft collar did significantly better

on outcomes such as pain, neck range of motion, neck stiffness, memory, and concentration.

Similarly, soft collar use is not associated with a greater decrease in pain when compared to rest,

exercises and mobilizations.27 “Acting as usual” showed significantly better outcomes on pain

and stiffness when compared to soft collar use.35 One systematic review showed only moderate

evidence that active intervention is more effective than soft collar use.24



Role of Education and Patient Educational Materials



                                                                                                 17
       Two systematic reviews26,32, one of high quality and one of moderate quality, reported

conflicting evidence on the effectiveness of educational techniques on symptom relief and long

term outcomes. The high quality review26 concluded that education techniques (described as any

learning experience intended to influence consumer health knowledge and behavior) had no

significant effect on pain relief, function/disability, patient satisfaction, knowledge transfer, or

behavioral change in adults with mechanical neck disorders.         Contrary to this finding, the

moderate quality study32 found that positive reassurance and evidence based advice given the

patients suffering from a whiplash injury, both in written and oral form, was an effective and

inexpensive intervention.

       A moderate quality RCT29 studied the effects of oral advice versus patient education

using a pamphlet in adults exposed to a motor vehicle collision. The trial concluded that there

was no significant difference in neck pain, headaches or neck disability between groups in the

short term (at three months) or long term (at twelve months). Another moderate quality RCT34

found that patients with an acute cervical sprain who viewed a cervical strain psycho-educational

video, compared to a control group who received no educational material, had dramatically

lower pain ratings, improved patient satisfaction and work days missed at one, three and six

months follow up.



Discussion

       Information    on    early   management,     types   of   intervention,   and    educational

materials/prognostic factors play an important role in the treatment of WAD I and II. This

scoping review found that, when compared to delayed treatment, management of WAD

consisting of active exercises and commencing within 4 days of the injury, produces beneficial



                                                                                                 18
effects on pain.33,36 In addition, early management promotes functional recovery and decreases

number of days off work.38         Therefore, physical therapy can be recommended in the

rehabilitative process, especially in the early stages of WAD recovery. Debate remains whether

early active intervention promotes an increase in cervical range of motion.22,38

       Active exercises are routinely incorporated into the treatment of WAD. There is good

evidence to suggest that general exercise and returning to regular activities has the greatest

benefit on recovery.27,31,33,35,36,38,39 Also, active therapy has been shown to be superior to no

treatment or immobilization.35,39 The literature suggests there is moderate to strong evidence that

soft collars should be avoided in patients with WAD I or WAD II. There is conflicting and

limited evidence on whether exercises for the cervical spine, which includes postural, neck

stabilization exercises or active range of motion are effective in the treatment of WAD.22,24,28

       There is much discussion regarding the effectiveness of passive treatments. The evidence

is highly limited and conflicting when determining if one mode is more effective than another.

It does appear though that when addressing patient symptoms directly, passive treatment is no

more effective than a placebo or no treatment at all.39

        Patient education is routinely used in the health care community and is generally

accepted as being valuable in patient centered care. There remains conflicting evidence on

whether educational techniques have short term symptom relief and/or long term benefits in

patients with WAD I or II.26,32 There appears to be no significant difference between educational

information delivered to the patient orally or written in a pamphlet.29 This literature search was

aimed at looking at the direct correlation of education and symptom relief. Patient education

may have indirect benefits by addressing fear avoidance, pain catastrophizing and self-




                                                                                                   19
management12, however literature was not reviewed (or found) that examined these relationships.

More research will be needed to examine these factors.



The Nose Creek Protocol

        The purpose of this study is to merge clinical opinion/expertise with research to ensure

best evidence based practice. When evaluating The Nose Creek protocol against the available

literature on early management, it is recommended to begin this program as soon as possible

after the injury as patients will experience more relief from symptoms earlier than a delayed

treatment. The program does state to see a physical therapist within one week following the

incident, but based on the literature it is recommended to amend this time to be within 4 days or

as soon as possible.33,36

        The protocol does follow best practice in that it recommends walking as a treatment and

general physical activity has been shown to be most beneficial. 27,31,33,35,36,38,39 The protocol also

recommends a series of active ROM exercises for the patient to perform. The evidence for this

specific activity in isolation is limited and therefore should be implemented at the treating

therapist’s discretion.28 The protocol could recommend that the patient participate in other

general physical activities such as swimming or yoga, for example. The specific activity and

intensity must be in collaboration with the treating therapist after a thorough assessment has been

completed to ensure safety. It is further advised by the literature that the protocol should

recommend returning to normal functioning of every-day-life as well.27,31,33,35,36,38,39

        Ice and heat are components of the protocol. These passive modalities are not supported

in the literature to directly provide improvement of symptoms and are no more effective than no

treatment.39 Ice and heat should not be stressed as a direct treatment method. As discussed



                                                                                                  20
above, there may be benefits to the patient-therapist relationship, but again more research is

required.

       Regarding patient education about their injury and whether the protocol is an effective

treatment for symptoms, the best available evidence suggests that it is not so. It appears to not

have an effect on pain and disability.26 The protocol does reassure the patient of a decrease in

symptoms and accelerated return to activity which is supported by the literature as being

effective.32 Clinicians may choose to use a written protocol with the goal of maintaining patient

compliance to the protocol and thus increasing therapeutic benefits. Evidence regarding patient

compliance with written protocols is beyond the scope of this review and cannot be commented

on regarding its effectiveness. More research will be required to examine this relationship.



Limitations of the Study

       The recommendations from this study can be helpful for guiding WAD I and II

management in the acute stage of injury, however, discretion should be used when applying the

information outside the search population. The search strategy used in this study included a

comprehensive look at research papers collected from a variety of databases; however, only

papers that were available online were included for review. This could have potentially excluded

useful information available only in printed journals. Regardless, the study acts as a step to

merging clinical opinion and research in the management of WAD injuries.



Outcome of the Project

       This project promotes knowledge transference between researcher and clinicians. A

handout of the results from this study will be developed and distributed at the 2010 Physical



                                                                                               21
Therapy Conference: Health in Motion, held at the University of Alberta. This handout will

include recommendations regarding early management, types of intervention, and educational

materials/prognostic factors. In addition, a summary of the results will be made available to the

Nose Creek Sport Physical Therapy team for their further use.




                                                                                              22
References

1. Allen M. Whiplash claims and costs in british columbia. BC Medical Journal 2002; 44(5),
241-242.

2. Berglund A, Bodin L, Jensen I, et al. The influence of prognostic factors on neck pain
intensity, disability, anxiety and depression over a 2-year period in subjects with acute whiplash
injury. Pain 2006; 125:244–56.

3. Carroll LJ, Hogg-Johnson S, van der Velde, G, et al. Course and prognostic factors for neck
pain in the general population. Results of the Bone and Joint Decade 2000–2010 Task Force on
Neck Pain and Its Associated Disorders. Spine 2008; 33(Suppl):S75–S82.

4. Carroll LJ, Hogg-Johnson S, Cote P, et al. Course and prognostic factors for
neck pain in workers. Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain
and Its Associated Disorders. Spine 2008; 33(Suppl):S93–S100.

5. Carroll LJ, Holm LW, Hogg-Johnson S, Cote P, Cassidy JD, Haldeman S, Nordin M,
Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM, Guzman J. Course and prognostic
factors for neck pain in whiplash associated disorders (WAD). Results of the Bone and Joint
Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 17(suppl
1):S83-S92.

6. Cassidy JD, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. Effect of eliminating
compensation for pain and suffering on the outcome of insurance claims for whiplash injury.
New England Journal of Medicine 2000; 342(16):1179-1186.

7. Cote P, Cassidy JD, Carroll L, Frank JW, Bombardier C. A systematic review of the
prognosis of acute whiplash and a new conceptual framework to synthesize the literature. Spine
2001; 26(19):E445-E458.

8. Elliot JM, Noteboom JT, Flynn TW, Sterling M. Characterization of acute and chronic
whiplash associated disorders. Journal of Orthopaedic & Sports Physical Therapy 2009; 29(5):
312-320.

9. Gross AR, Kay T, Hondras M, Goldsmith C, Haines T, Peloso P, Kennedy C, Hoving J.
Manual therapy for mechanical neck disorders: a systematic review. Manual Therapy 2002; 7(3):
131-149.

10. Holmes R. The Nose Creek Sport Physical Therapy Clinic. Teleconference on September 30,
2009.

11. Maher CG, Sherrington C, Herbert RD, Moselet AM, Elkins M. Reliability of the PEDro
scale for rating quality of randomized controlled trials. Physical Therapy 2003; 83(8): 713-721.

12. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive
neurophysiology education in chronic low back pain. Clin J Pain 2004; 20(5): 324-30.

                                                                                                23
13. Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine:How to Practice
and Teach EBM. Philadelphia, Pa: Churchill-Livingstone; 2000.

14. Sakzewski L, Ziviani J, Boyd R. Systematic review and meta-analysis of therapeutic
management of upper-limb dysfunction in children with congenital hemiplegia. Pediatrics 2009;
123(6):e1111-22.

15. Scholten-Peeters GG, Verhagen AP, Bekkering GE, van der Windt DA, Barnsley L,
Oostendorp RA et al. Prognostic factors of whiplash-associated disorders: a systematic review of
prospective cohort studies. Pain 2003; 104(1-2):303-322.

16. Shea BJ, Bouter LM, Peterson J, Boers M, Andersson N, Ortiz Z, Ramsay T, Bai A, Shukla
VK, Grimshaw JM. External Validation of a Measurement Tool to Assess Systematic Reviews
(AMSTAR). PLoS ONE 2007; 2(12):e1350.

17. Shea BJ, Grimshaw JM, Wells G A, Boers M, Andersson N, Hamel C, et al. Development of
AMSTAR: A measurement tool to assess the methodological quality of systematic reviews.
BMC Medical Research Methodology 2007; 7:10.

18. Sherrington C, Herbert RD, Maher CG, Moseley AM. PEDro. A database of randomized
trials and systematic reviews in physiotherapy. Man Theory 2000; 5:223-6.

19. Sizer PS, Poorbaugh K, Phelps V. Whiplash associated disorder: pathomechanics, diagnosis,
and management. Pain Practice 2004; 4(3): 249-266.

20. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force
on whiplash-associated disorders: redefining "whiplash” and its management [erratum in Spine
1995;20:2372]. Spine 1995; 20:1S-73.

21. Wells GA, et al. The newcastle-ottawa scale (NOS) for assessing the quality of
nonrandomised studies in meta-analyses. Retrieved October/14, 2009, from
http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm


References of Included Systematic Reviews and Randomized Controlled Trials
22. Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash-associated disorders: Part
    I: Noninvasive interventions. Pain Res Manage 2005; 10(1): 21-32.
23. Dehner C, Elbel M, Strobel P, Scheich M, Schneider F, Krischak G, & Kramer M. Grade II
    whiplash injuries to the neck: what is the benefit for patients treated by different physical
    therapy modalities? BioMed Central 2009; 3(2): 1-8.
24. Drescher K, Hardy S, MacLean J, Schindler M, Scott K, Harris SR. Efficacy of Postural and
    Neck-Stabilization Exercises for Persons with Acute Whiplash-Associated Disorders: A
    Systematic Review. Physiother Can. 2008; 60: 215-223.
25. Gonzales-Iglesias J, Fernandez-De-Ls-Penas C, Cleland J, Huijbregts P, Gutierrez-Vega
    MDR. Short-Term Effects of Cervical Kinesio Taping on Pain and Cervical Range of

                                                                                               24
    Motion in Patients With Acute Whiplash Injury: A Randomized Clinical Trial. Journal of
    Orthopaedic & Sports Physical Therapy 2009;39(7): 515-521.
26. Haines T, Gross A, Goldsmith CH, & Perry L. Patient education for neck pain with or
    without radiculopathy. Cochrane Database of Systematic Reviews 2008; (4): 005106.
27. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM,
    Holm LW, Cote P, Hogg-Johnson S, Cassidy JD, Haldeman S. Bone and Joint Decade
    2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl):
    S123-52.
28. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G, et al. Exercises for
    mechanical neck disorders. Cochrane Database of Systematic Reviews 2005; (3): 004250.
29. Kongsted A, Qerama E, Kasch H, Bach FW, Korsholm L, Jensen TS, et al. Education of
    patients after whiplash injury: Is oral advice any better than a pamphlet? Spine 2008;
    33(22): E843-8.
30. Kroeling P, Gross AR, Goldsmith CH, & Cervical Overview, G. A cochrane review of
    electrotherapy for mechanical neck disorders. Spine 2005; 30(21): E641-8.
31. Lundmark H & Persson AL. Physiotherapy and management in early whiplash-associated
    disorders (WAD) – A review. Advances in Physiotherapy 2006; 8: 98-105.
32. McClune T, Burton AK., & Waddell G. Whiplash associated disorders: A review of the
    literature to guide patient information and advice. Emergency Medicine Journal 2002;
    19(6): 499-506.
33. Mercer C, Jackson A, Moore A. Developing clinical guidelines for the physiotherapy
    management of whiplash associated disorder (WAD). International Journal of
    Osteopathic Medicine 2008; 10(2-3): 50-54.
34. Oliveira A, Gevirtz R, & Hubbard D. A psycho-educational video used in the emergency
    department provides effective treatment for whiplash injuries. Spine 2006; 31(15): 1652-
    1657.
35. Peeters GG, Verhagen AP, de Bie RA, & Oostendorp RA. The efficacy of conservative
    treatment in patients with whiplash injury: A systematic review of clinical trials. Spine
    2001; 26(4): E64-73.
36. Sarig-Bahat H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy
    2003; 8(1): 10-20.
37. Scholten-Peeters G. Whiplash and its treatment. Dutch Journal of Physical Therapy 2007;
    117(3): 96-97.
38. Seferiadis A, Rosenfeld M, & Gunnarsson R. A review of treatment interventions in
     whiplash associated disorders. European Spine Journal 2004; 13(5): 387-397.
39. Verhagen AP, Scholten-Peeters GG, van Wijngaarden S, de Bie RA, & Bierma-Zeinstra SM.
    Conservative treatments for whiplash. Cochrane Database of Systematic Reviews 2007; (2):
    003338.




                                                                                                25
Appendix 1 – The Nose Creek Sports Physical Therapy Protocol

Home Program for Recent MVA Injury (WAD 1 and WAD 2)

Ice – Use ice only, the first 3-4 days post injury. Place the ice-pack in a pillowcase (use
conventional ice-pack, frozen peas or crushed ice) and apply to sore area for 15 minutes 3-6
times per day.

ROM (Range of Motion) – See the illustrations below for gentle, slow pain free range of motion
exercises to assist you with your recovery. These should be done three times per day within pain
free range.

Heat – After the first 3-4 days, you can alternate between heat and ice. The best type of heat is
moist heat. Hot bath, hot shower or a heating pad 2-3 times per day for 15-20 minutes is
beneficial for reducing your symptoms.

Walking – 2-3 times per day for 10-30 minutes. Walking helps your recovery by getting your
blood flowing, keeping you mobile and reducing stiffness. At the beginning, keep to a moderate
walking pace and flat ground. You may progress terrain and speed as you feel comfortable.

   See your Physical Therapist within 1 week of the accident for initial assessment, to start
       treatment and receive education on the self management of your specific injuries.
   If you manage your injury well in the first 2 weeks, you will progress faster with your
       recovery and return to your normal activities sooner.

1. Neck Flexion – 10 times                           2. Neck rotation – 10 times
   Gently look down then return to neutral            Turn head slowly left and right




                      3. Trunk rotation – 10 times




                      Cross arms on shoulders, sit tall and turn
                      trunk slowly from left to right.




                                                                                                26
Appendix 2 – EMBASE and Medline Search Algorithm
EMBASE – Treatment Search Algorithm
1. exp Whiplash Injuries/
2. exp "Physical Therapy (Specialty)"/ or exp Physical Therapy Modalities/
3. (physiotherap* or physical therap*).mp. [mp=title, abstract, subject headings, heading word, drug trade name,
original title, device manufacturer, drug manufacturer name]
4. (physiotherap* or physical therap*).jw.
5. 4 or 3 or 2
6. 1 and 5
7. (neck adj3 (flexion* or rotation* or "range of motion" or ROM)).mp. [mp=title, abstract, subject headings,
heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
8. exp Hot Temperature/
9. (heat* or cold or ice).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,
device manufacturer, drug manufacturer name]
10. exp Cold Temperature/
11. exp Walking/
12. (walk or walks or walking).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original
title, device manufacturer, drug manufacturer name]
13. 8 or 11 or 7 or 10 or 9 or 12
14. 1 and 13
15. 6 or 14
16. ((early or acute or post-injury) and (therap* or manag* or treat*)).mp. [mp=title, abstract, subject headings,
heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
17. 16 and 15
18. (whiplash or (mechanical* adj3 neck)).mp. [mp=title, abstract, subject headings, heading word, drug trade name,
original title, device manufacturer, drug manufacturer name]
19. 1 or 18
20. 19 and 5
21. 19 and 13
22. 21 or 20
23. exp cold/ or exp cold treatment/
24. exp heat/ or exp heat treatment/
25. 24 or 23 or 13
26. 25 and 19




                                                                                                                      27
Medline – Treatment Search Algorithm
1. exp Whiplash Injuries/
2. exp "Physical Therapy (Specialty)"/ or exp Physical Therapy Modalities/
3. (physiotherap* or physical therap*).mp. [mp=title, original title, abstract, name of substance word, subject
heading word]
4. (physiotherap* or physical therap*).jw.
5. 4 or 3 or 2
6. 1 and 5
7. (neck adj3 (flexion* or rotation* or "range of motion" or ROM)).mp. [mp=title, original title, abstract, name of
substance word, subject heading word]
8. exp Hot Temperature/
9. (heat* or cold or ice).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
10. exp Cold Temperature/
11. exp Walking/
12. (walk or walks or walking).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
13. 8 or 11 or 7 or 10 or 9 or 12
14. 1 and 13
15. 6 or 14
16. ((early or acute or post-injury) and (therap* or manag* or treat*)).mp. [mp=title, original title, abstract, name of
substance word, subject heading word]
17. 16 and 15
18. (whiplash or (mechanical* adj3 neck)).mp. [mp=title, original title, abstract, name of substance word, subject
heading word]
19. 1 or 18
20. 19 and 5
21. 19 and 13
22. 21 or 20


EMBASE – Education and Time Search Algorithm
1. exp Whiplash Injuries/
2. exp "Physical Therapy (Specialty)"/ or exp Physical Therapy Modalities/
3. (physiotherap* or physical therap*).mp. [mp=title, abstract, subject headings, heading word, drug trade name,
original title, device manufacturer, drug manufacturer name]
4. (physiotherap* or physical therap*).jw.
5. 4 or 3 or 2
6. 1 and 5

                                                                                                                      28
7. (neck adj3 (flexion* or rotation* or "range of motion" or ROM)).mp. [mp=title, abstract, subject headings,
heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
8. exp Hot Temperature/
9. (heat* or cold or ice).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,
device manufacturer, drug manufacturer name]
10. exp Cold Temperature/
11. exp Walking/
12. (walk or walks or walking).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original
title, device manufacturer, drug manufacturer name]
13. 8 or 11 or 7 or 10 or 9 or 12
14. 1 and 13
15. 6 or 14
16. ((early or acute or post-injury) and (therap* or manag* or treat*)).mp. [mp=title, abstract, subject headings,
heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
17. 16 and 15
18. (whiplash or (mechanical* adj3 neck)).mp. [mp=title, abstract, subject headings, heading word, drug trade name,
original title, device manufacturer, drug manufacturer name]
19. 1 or 18
20. 19 and 5
21. 19 and 13
22. 21 or 20
23. exp cold/ or exp cold treatment/
24. exp heat/ or exp heat treatment/
25. 24 or 23 or 13
26. 25 and 19
27. exp time/
28. ((time or timing or early) adj3 (treat* or manag* or therap* or interven*)).mp. [mp=title, abstract, subject
headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
29. 27 or 28
30. 19 and 29
31. exp patient education/
32. ((educat* or train* or teach*) adj3 patient*).mp. [mp=title, abstract, subject headings, heading word, drug trade
name, original title, device manufacturer, drug manufacturer name]
33. 31 or 32
34. 19 and 33



                                                                                                                      29
35. evaluation.mp. or exp "evaluation and follow up"/ or exp clinical evaluation/ or exp evaluation/ or exp
evaluation research/
36. limit 33 to ("reviews (2 or more terms high specificity)" or "treatment (1 term high specificity)" or "treatment (2
or more terms high specificity)")
37. 33 and 35
38. 36 or 37
39. 19 and 38


Medline – Education and Time Search Algorithm
jb Jan 18 2010
1. exp Whiplash Injuries/
2. exp "Physical Therapy (Specialty)"/ or exp Physical Therapy Modalities/
3. (physiotherap* or physical therap*).mp. [mp=title, original title, abstract, name of substance word, subject
heading word, unique identifier]
4. (physiotherap* or physical therap*).jw.
5. 4 or 3 or 2
6. 1 and 5
7. (neck adj3 (flexion* or rotation* or "range of motion" or ROM)).mp. [mp=title, original title, abstract, name of
substance word, subject heading word, unique identifier]
8. exp Hot Temperature/
9. (heat* or cold or ice).mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique
identifier]
10. exp Cold Temperature/
11. exp Walking/
12. (walk or walks or walking).mp. [mp=title, original title, abstract, name of substance word, subject heading word,
unique identifier]
13. 8 or 11 or 7 or 10 or 9 or 12
14. 1 and 13
15. 6 or 14
16. ((early or acute or post-injury) and (therap* or manag* or treat*)).mp. [mp=title, original title, abstract, name of
substance word, subject heading word, unique identifier]
17. 16 and 15
18. (whiplash or (mechanical* adj3 neck)).mp. [mp=title, original title, abstract, name of substance word, subject
heading word, unique identifier]
19. 1 or 18
20. 19 and 5

                                                                                                                      30
21. 19 and 13
22. 21 or 20
23. (early adj3 (intervention or manag* or treat*)).mp. [mp=title, original title, abstract, name of substance word,
subject heading word, unique identifier]
24. exp Time Factors/
25. 23 or 24
26. timing.mp.
27. 25 or 26
28. 22 and 27
29. exp Patient Education as Topic/
30. exp Patient Education Handout/
31. ((educat* or train* or teach*) adj3 patient*).mp. [mp=title, original title, abstract, name of substance word,
subject heading word, unique identifier]
32. 29 or 30 or 31
33. 19 and 32
34. exp Program Evaluation/
35. limit 32 to (clinical trial, all or clinical trial or comparative study or controlled clinical trial or evaluation studies
or meta analysis)
36. 34 or 35
37. 19 and 36




                                                                                                                           31
Appendix 3 – AMSTAR Appraisal Tool16

AMSTAR
1. Was an ‘a priori’ design provided?                                     r Yes
The research question and inclusion criteria should be established before r No
the conduct of the review.                                                r Can’t answer
                                                                          r Not applicable

2. Was there duplicate study selection and data extraction?              r Yes
There should be at least two independent data extractors and a consensus r No
procedure for disagreements should be in place.                          r Can’t answer
                                                                         r Not applicable

3. Was a comprehensive literature search performed?                           r Yes
At least two electronic sources should be searched. The report must           r No
include years and databases used (e.g. Central, EMBASE, and                   r Can’t answer
MEDLINE). Key words and/or MESH terms must be stated and where                r Not applicable
feasible the search strategy should be provided. All searches should be
supplemented by consulting current contents, reviews, textbooks,
specialized registers, or experts in the particular field of study, and by
reviewing the references in the studies found.


4. Was the status of publication (i.e. grey literature) used as an            r Yes
inclusion criterion?                                                          r No
The authors should state that they searched for reports regardless of their   r Can’t answer
publication type. The authors should state whether or not they excluded       r Not applicable
any reports (from the systematic review), based on their publication
status, language etc.

5. Was a list of studies (included and excluded) provided?                    r Yes
A list of included and excluded studies should be provided.                   r No
                                                                              r Can’t answer
                                                                              r Not applicable

 6. Were the characteristics of the included studies provided?                r Yes
In an aggregated form such as a table, data from the original studies         r No
should be provided on the participants, interventions and outcomes. The       r Can’t answer
ranges of characteristics in all the studies analyzed e.g. age, race, sex,    r Not applicable
relevant socioeconomic data, disease status, duration, severity, or other
diseases should be reported.




                                                                                                 32
7. Was the scientific quality of the included studies assessed and             r Yes
documented?                                                                    r No
‘A priori’ methods of assessment should be provided (e.g., for                 r Can’t answer
effectiveness studies if the author(s) chose to include only randomized,       r Not applicable
double-blind, placebo controlled studies, or allocation concealment as
inclusion criteria); for other types of studies alternative items will be
relevant.



8. Was the scientific quality of the included studies used                     r Yes
appropriately in formulating conclusions?                                      r No
 The results of the methodological rigor and scientific quality should be      r Can’t answer
considered in the analysis and the conclusions of the review, and              r Not applicable
explicitly stated in formulating recommendations.

9. Were the methods used to combine the findings of studies                    r Yes
appropriate?                                                                   r No
For the pooled results, a test should be done to ensure the studies were       r Can’t answer
combinable, to assess their homogeneity (i.e. Chi-squared test for             r Not
homogeneity, I²). If heterogeneity exists a random effects model should         applicable
be used and/or the clinical appropriateness of combining should be taken
into consideration (i.e. is it sensible to combine?).

10. Was the likelihood of publication bias assessed?                           r Yes
An assessment of publication bias should include a combination of              r No
graphical aids (e.g., funnel plot, other available tests) and/or statistical   r Can’t answer
tests (e.g., Egger regression test).                                           r Not applicable

11. Was the conflict of interest stated?                                r Yes
Potential sources of support should be clearly acknowledged in both the r No
systematic review and the included studies.                             r Can’t answer
                                                                        r Not applicable




                                                                                                  33
Appendix 4 – PEDro Scale17

PEDro scale

1. eligibility criteria were specified no _ yes _ where:

2. subjects were randomly allocated to groups (in a crossover study, subjects

were randomly allocated an order in which treatments were received) no _ yes _ where:

3. allocation was concealed no _ yes _ where:

4. the groups were similar at baseline regarding the most important prognostic

indicators no _ yes _ where:

5. there was blinding of all subjects no _ yes _ where:

6. there was blinding of all therapists who administered the therapy no _ yes _ where:

7. there was blinding of all assessors who measured at least one key outcome no _ yes _ where:

8. measures of at least one key outcome were obtained from more than 85%

of the subjects initially allocated to groups no _ yes _ where:

9. all subjects for whom outcome measures were available received the

treatment or control condition as allocated or, where this was not the case,

data for at least one key outcome was analysed by “intention to treat” no _ yes _ where:

10. the results of between-group statistical comparisons are reported for at least one

key outcome no _ yes _ where:

11. the study provides both point measures and measures of variability for at

least one key outcome no _ yes _ where:




                                                                                             34
Appendix 5 – Data Extraction Table of Systematic Reviews

Author     Design      Score Subjects    Intervention       Outcome         Results
                                                            Measures
Conlin et. Systematic 7/11 Adults        Non-invasive       Pain (VAS       RCT studies:
al (2005) Review           (18+) with    interventions      scale, PDI      Active treatment resulted in
           (RCTs,          acute or      (exercise,         scale, or       significant improvements in pain (but
           epidemiologi    chronic       multimodal         subjective      not ROM) and was better when
           cal studies,    whiplash      intervention       reports)        provided earlier than later.
           cohorts         injury        with exercise,     Cervical ROM Patients with additional exercises to
           studies, case                 mobilization,      Cervicothoracic improve kinesthetic sensibility and
           control and                   and pulsed         posture and     neck muscle coordination compared
           case series)                  magnetic field     kinaesthetic    had no significant improvement in
                                         treatments) for    sensibility     pain, physical parameters or function
                                         the treatment of   Self-efficacy at 6 months.
                                         WAD                scale           Conflicting evidence on effectiveness
                                                            Function:       of exercise in conjunction with
                                                            global          multimodal interventions (e.g.
                                                            improvement relaxation training, functional
                                                            and number of behavioural analysis, cervical spine
                                                            patients        mobilization, psychological support,
                                                            returned to     etc.)
                                                            work            Patients who did not use a soft collar
                                                                            did significantly better on outcome
                                                                            measures such as pain, neck ROM
                                                                            and stiffness, memory and
                                                                            concentration.
                                                                            One study reported improvements in
                                                                            pain and ROM in patients with WAD
                                                                            of undefined duration who were
                                                                            treated with pulsed electromagnetic
                                                                            field treatment.
Drescher   Systematic 7/11 Adults       Postural and/or     Pain (VAS or Moderate evidence to support use of
et. al     Review          (18+) with neck                  PDI scale)      postural exercises and advice for
(2008)     (RCTs and       acute (less stabilization        Neck ROM        decreasing pain and time off work,
           quasi-          han 6        exercises           Length of time and conflicting evidence on use of
           randomized      months                           off work        neck stabilization exercises.
           clinical        duration)                                        No significant evidence found to
           trials)         with WAD                                         support use of postural and neck
                           sustained in                                     stabilization exercises to increase
                           an MVA.                                          cervical ROM.
                                                                            Moderate evidence that active
                                                                            intervention is more effective than
                                                                            soft collar immobilization to treat
                                                                            acute WAD.




                                                                                                               35
Haines et Systematic 11/11 Adults     Assess whether Pain relief,       Review has not shown effectiveness
al. (2008) review          (18+) with educational      disability or    of educational interventions.
           (RCTs &         acute (<30 techniques       function, global Advice focusing on activation –
           quasi-RCTs)     days),     either alone or perceived         showed either inferiority or no
                           subacute   in combination effect, quality difference for pain, when compared
                           (30-90     with other       of life and      to no treatment or various other
                           days), or  treatments are patient            treatments.
                           chronic    of benefit for satisfaction       Advice focusing on pain & stress
                           (90+days) affecting: pain, Secondary         coping skills – moderate evidence or
                           neck       function/disabil outcomes:        no benefit for pain in chronic WAD
                           disorders ity, patient      knowledge        at intermediate/long term follow up.
                                      satisfaction,    transfer,        Traditional neck school – limited
                                      ratings of       behavior         evidence shows that there is no
                                      overall          change, adverse benefit for pain at intermediate
                                      effectiveness, events and cost follow up, when compared to no
                                      knowledge        of care          treatment.
                                      transfer, or
                                      behavioral
                                      change in adults
                                      with
                                      mechanical
                                      neck disorders.
                                      Educational
                                      techniques are
                                      described as
                                      any learning
                                      experience
                                      intended to
                                      influence
                                      consumer
                                      health
                                      knowledge and
                                      behavior.




                                                                                                          36
Hurwitz, Systematic   7/11 Patients Pulsed           Symptoms,   PEMT was found to benefit
E.L. et al. Review         with WAD ElectroMagneti pain          symptoms when compared to
(2008)                              c Therapy                    placebo.
                                    (PEMT),                      Mobilizations and exercise or
                                    mobilizations,               supervised training showed a short
                                    exercises,                   term benefit over passive modalities,
                                    passive                      collars, or simple advice.
                                    modalities,                  Educational videos about exercising
                                    collars, advice,             as soon as possible after injury were
                                    educational                  effective for symptom reduction.
                                    videos,                      Lack of evidence to support cervical
                                    manipulations,               spine or thoracic spine manipulations
                                    traction                     or traction to reduce symptoms.
                                                                 Inconsistent evidence that exercises
                                                                 were positively associated with more
                                                                 favourable prognosis in the short or
                                                                 long term when compared to passive
                                                                 treatment including education.
                                                                 Mobilizations were more effective in
                                                                 the short term for pain reduction
                                                                 compared to collars, passive
                                                                 modalities, and advice, but were as
                                                                 effective as staying active.
                                                                 Passive modalities not associated
                                                                 with reduction of pain compared to
                                                                 exercises and manual therapy.
                                                                 Soft collar use is not associated with
                                                                 a greater decrease in pain compared
                                                                 to rest, exercises, and mobilizations.




                                                                                                    37
Kay et al. Systematic 11/11 Adults       Assess the       Pain, measures There is strong evidence for
(2009)      review          (18+) with effectiveness of of                 multimodal care approach of exercise
            (RCTs &         acute (<30 exercise therapy function/disabil combined with mobilization and
            quasi-RCTs)     days),       to relieve pain ity, patient      manipulation for subacute and
                            subacute     or improve       satisfaction,    chronic MND .
                            (30-90       function,        global           Eye-fixation exercises program
                            days), or    disability,      perceived effect shows limited evidence for benefits
                            chronic      patient                           for pain, function, and perceived
                            (90+days) satisfaction, and                    effect for acute/subacute WAD
                            neck         global                            There is limited evidence for the
                            disorders perceived effect                     benefit of AROM on reducing pain
                                         in adults with                    in acute WAD. There is limited
                                         mechanical                        evidence of benefit on pain relief for
                                         neck disorders.                   a home mobilization program with
                                         Exercise                          physical modalities, over a program
                                         therapy                           of rest and gradual mobilization for
                                         included: neck                    acute WAD.
                                         exercises,
                                         shoulder
                                         exercises,
                                         active
                                         exercises,
                                         stretching,
                                         strengthening,
                                         postural,
                                         functional, eye
                                         fixation, and
                                         proprioception
                                         exercises
Kroeling et Systematic 8/11 525          Assess whether Pain relief,       Galvanic current – unable to
al. 2005    review          participants electrotherapy disability/functi determine contribution to treatment
            (RCTs &         Adults       relieves pain or on, patient      of occipital headaches.
            quasi-RCTs)     (18+) who improves            satisfaction,    Modulated galvanic current – no
                            have acute function/disabil global             detectable difference in effect on
                            (<30 days), ity in adults     perceived effect trigger point tenderness between
                            sub-acute with                                 daily application
                            (30-90       mechanical                        Iontophoresis – contribution could
                            days) and neck disorders.                      not be determined
                            chronic      Electrotherapy                    TENS – evidence is conflicting
                            (>90days) included:                            EMS – limited evidence that a single
                            neck         galvanic                          treatment has no detectable effect on
                            disorders current, TENS,                       trigger point tenderness
                                         EMS (electrical                   Permanent magnets – there is limited
                                         muscle                            evidence that this modality is not
                                         stimulations),                    effective for participants with
                                         PEMF (pulsed                      chronic neck pain
                                         electromagnetic                   PEMF – there is limited evidence
                                         fields) &                         that high-frequency PEMF only
                                         permanent                         reduces pain for participants with
                                         magnets                           acute/chronic MND immediately
                                                                           post treatment




                                                                                                              38
Lundmark Systematic     6/11 1230         Early            Time to            Suggestions for early management:
& Persson, review            patients     management       recovery, self-    quick return to normal activities, pain
(2006)     (RCTs and         with WAD     that             efficacy scales,   relief, home exercises to maintain
           CTs)              I-III        physiotherapists coping             Csp movement, posture and coping
                              8 studies   can provide      strategies,        strategies to handle disability due to
                                          WAD I-III        disability, pain   neck pain.
                                          patients, to     intensity,         Advice to act as usual as well as
                                          minimize         cervical ROM       active treatment is preferred in early
                                          chronic pain                        WAD I-III.
                                          and disability                      The use of soft collars should be
                                                                              avoided in WAD I-III.
McClune   Systematic 5/11 Not stated      Patient          N/A                Information and advice should be
et al.    review          163 studies     information                         given to patients with WAD as soon
(2002)    (Review of                      Review of                           after injury as is reasonable. Positive
          literature on                   literature to                       reassurance and evidence based
          pt.                             provide an                          advice, given consistently in both
          information)                    evidence based                      oral and written form, is an attractive
                                          framework for                       and inexpensive intervention
                                          patient centered                    Main messages that emerged:
                                          information and                     Physical serious injury is rare,
                                          advice on                           reassurance about good prognosis is
                                          WAD.                                important, recovery is improved by
                                                                              early return to normal pre-accident
                                                                              activities/self exercise/manual
                                                                              therapy, negative attitudes and
                                                                              beliefs delay recovery and contribute
                                                                              to chronicity.
Mercer, C. Systematic   5/11 Adults,  Active          Symptoms,               Strong evidence: 1) Active exercises
et al.     Review            Patients exercises,     pain                     decrease pain when started within 4
(2007)                       with WAD education,                              days after injury. 2) Education on
                                      manual                                  self management will decrease
                                      mobilizations,                          symptoms. 3) Returning to normal
                                      soft collar,                            activities is beneficial.
                                      advice on                               Moderate evidence that manual
                                      resuming                                mobilizations should be conducted to
                                      normal                                  decrease pain.
                                      activities                              Consensus opinion: 1) Soft collar
                                                                              should not be used. 2) active
                                                                              exercises, advice, and education
                                                                              should be used in early treatment.




                                                                                                                  39
Peeter, G. Systematic    8/11 Patients Soft collar     Pain, range of    Activity was shown to be better than
et al.     Review             with WAD immobilization, motion (ROM),    immobilization for decreasing pain
(2001)                                 early active    days off work,   and increasing ROM.
                                       mobilization, stiffness          No significant difference between
                                       PEMT, and                        collar use and activity, but study was
                                       multimodal                       of poor quality.
                                       treatment, "Act                  PEMT was beneficial initially (2-4
                                       as Normal"                       weeks) when compared to control,
                                                                        but no difference at 12 weeks.
                                                                        Multimodal treatment has a positive
                                                                        effect on pain in both the short and
                                                                        long term with reduced number of
                                                                        days of work.
                                                                        "Act as normal" showed significantly
                                                                        better outcomes (pain and stiffness)
                                                                        when compared to soft collar use.
Sarig-    Systematic     7/11 Human    Various active Pain              Early mobilization was effective in
Bahat, H. Review                       exercises:
                              adults over                               decreasing pain and encouraging
(2003)                                 stretching,
                              18 years of                               recovery.
                              age with strengthening,                   Active exercises were beneficial for
                                       endurance and
                              mechanical                                treating acute whiplash, with best
                              neck     aerobic                          result occurring when treatment was
                              disorder training,                        introduced early (within 96hrs).
                              includingpostural                         Active neck-shoulder training and
                              WAD I andcorrection,                      relaxation was shown to be
                              II       neuromuscular                    beneficial.
                                       control and
                                       movement
                                       awareness
Seferiadis, Systematic   7/11 Patients Early physical Pain, ROM,        Early physical activity was shown to
A. et al.   Review            with WAD activity, PEMT days off work     decrease pain, increase ROM, and
(2004)                                                                  decrease the number of days off
                                                                        work.
                                                                        PEMT is not recommended despite
                                                                        high quality evidence for it's
                                                                        effectiveness. The equipment is
                                                                        collar mounted and thus conflicts
                                                                        with evidence regarding negative
                                                                        effects of collars.




                                                                                                           40
Verhagen, Systematic   11/11 Patients Non-surgical, Symptoms,            Passive treatment is not more
A. et al. Review             with WAD non-invasive     pain, return to   effective than placebo or no
(2007)                       I and II treatments,      work time         treatment for relieving symptoms.
                                      passive                            PEMT was more effective than
                                      treatment (soft                    placebo for reducing pain.
                                      collar,                            Active exercises, traction, and
                                      modalities,                        massage significantly reduced pain
                                      rest), early                       compared to no treatment.
                                      active                             Conflicting evidence of effectiveness
                                      mobilization,                      active exercises versus passive
                                      PEMT, laser                        treatments to decrease symptoms.
                                      acupuncture,                       Comparing active exercises, no
                                      multimodal                         approach was more effective than
                                      treatment,                         another to decrease pain and time to
                                      psycho-                            return to work
                                      educational
                                      videos, active
                                      exercises
                                      (mobilization
                                      exercises and
                                      kinaesthetic/co-
                                      ordination
                                      exercises)




                                                                                                           41
Appendix 6 – Data Extraction Table of Randomized Controlled Trials
Author   Design Score Subjects        Intervention      Outcome          Results
                                                        Measures
Dehner et RCT   6/10 70 subjects (3  8 weeks             Pain scores,      Both physical therapy groups showed
al. 2009             excluded)       Active physical cervical ROM, no deficits in median ROM, while the
                     with QTF II     therapy (APT) vs. period of           control group had a median deficit of
                     whiplash        passive physical disability/          10 degrees. There were no
                     injury treated  therapy (PPT)       sickness costs statistically significant differences
                     in emergency    (PPT) vs. control                     between the two groups receiving
                     department      (“act-as-usual”)                      physical therapy.
                     Ages 18-52      Groups:                               The APT showed a significantly
                     years old       PPT: moist heat,                      greater median improvement in pain
                                     classic massage,                      than the PPT.
                                     electrotherapy                        The two physical therapy groups did
                                     APT: Week 2 -                         not differ significantly in period of
                                     soft tissue                           disability.
                                     treatment, trigger
                                     point, joint
                                     mobilization.
                                     Week 3 – Above,
                                     coordination
                                     training,
                                     stabilization
                                     techniques.
                                     Week 6 – Above,
                                     3 dimensional
                                     training.
                                     Week 8 – Above,
                                     specific joint
                                     mobilization of
                                     spine.
                                     Act as usual:
                                     patients instructed
                                     to resume usual
                                     activities without
                                     modification.
Gonzalez- RCT   9/10 41              The real Kinesio Numerical pain Statistical improvements in neck pain
Inglesias            consecutive Tape group had rating scale               and cervical range of motion, but
et. al               patients        Kinesio Tape        (NPRS) for the changes were small and results did not
(2009)               (mean age of over the posterior neck – 0 is no surpass the minimal clinically
                     33 +/- 7 years, cervical extensor pain and 10 is important difference for pain and
                     52% female) muscles with            max pain          range of motion.
                     with WAD II paper-off tension.
                     within 40       The sham Kinesio Cervical range
                     days of injury group had tape       of motion into
                                     application that flexion,
                                     looked similar but extension, right
                                     no tension applied and left rotation
                                     to cervical         and lateral
                                     structures.         flexion using
                                                         cervical range
                                                         of motion
                                                         device placed
                                                         on the top of the
                                                         head

                                                                                                             42
Kongsted RCT 5/10 182                Education for       3, 6, 12 month 3 month follow-up: no significant
et al. 2008 (prosp   participants patients:              follow-ups       group differences were observed on
            ective   Ages 18-70 Oral advice              collected via    any outcome measure
            study)   years old       (personally         mailed           6 month follow-up: disability was
                     Exposed to communicated             questionnaires significantly less frequent in the oral
                     rear-end or     advice) vs. patient Average neck advice group than the pamphlet group.
                     frontal care education using a pain and              12 month follow-up: outcome did not
                     collision with pamphlet             headache (11- differ between the intervention groups
                     a pain score Oral advice: 1 hr point box
                     <4/10 and       session at home to scale), neck
                     cervical ROM reduce pain and disability
                     at least 240 uncertainty,           (Copenhagen
                     degrees         describe whiplash Neck
                                     mechanism,          Functional
                                     discuss prognosis, Disability
                                     explain pain,       Scale)
                                     motivate
                                     participant to
                                     return to normal
                                     activity.
                                     Pamphlet group:
                                     received the same
                                     information but in
                                     an 8 page booklet.
Oliveria et RCT 5/10 126 subjects Treatment group Follow-up via a Patients viewing the video had
al. 2006             diagnosed       viewed a cervical telephone          dramatically lower pain ratings at 1, 3,
                     with an acute strain psycho-        questionnaires and 6 month follow-ups.
                     cervical strain educational video. at 1, 3, 6        The other scales used assessed patient
                                     This group was months. If this satisfaction, life changes as a result of
                                     also discharged was not              injury and work days missed – in each
                                     home with a neck possible after 3 of the cases, the video group was more
                                     strain aftercare    attempts,        improved than the control group
                                     instruction sheet questionnaires (p<0.001).
                                     and video           were mailed
                                     summary sheet. out.
                                     Control group       The Short
                                     received no         Musculoskeletal
                                     educational         Function
                                     material .          Assessment,
                                                         The Utilization
                                                         Measure
                                                         modified from
                                                         the North
                                                         Carolina Back
                                                         Pain Projects
                                                         Instrument,
                                                         Level of Patient
                                                         Satisfaction,
                                                         The Verbal
                                                         Rating Scale,
                                                         Legal
                                                         Involvement.




                                                                                                               43
Scholten-   RCT   7/10 80 patients   Active treatment    Primary          GP care showed significantly better
Peerers,               Acute WAD (education and          measures: neck results for functional recovery,
2007                   grade I or II advice) by          pain, headache disability in housekeeping, and social
                       with          general             intensity, work activities.
                       symptoms of practitioners VS.     activities in    PT treatment scored better than GP
                       neck pain,    active treatment    daily life       care on cervical ROM, although not
                       headache, or (education,          (scored on       all comparisons were statistically
                       dizziness.    advice, active      VAS)             significant
                       Qualification exercise therapy)   Secondary        Statistically significant differences
                       period of 4   by physical         measures:        were only found in favour of PT for
                       weeks – only therapists           functional       cervical rotation at 12 weeks, and in
                       those who did Details of          recovery         favour of GP care for functional
                       not recover treatment not         (VAS), general recovery, coping strategies, physical
                       would be      provided.           health status    functioning and bodily pain at 52
                       randomized to                     (SF-36), Csp weeks.
                       the                               ROM, fear of
                       interventions                     movement
                                                         (Tampa Scale
                                                         for
                                                         Kinesiophobia),
                                                         coping (Pain
                                                         Coping
                                                         Inventory),
                                                         disability (Neck
                                                         disability
                                                         Index), and
                                                         disability in
                                                         housekeeping
                                                         and social
                                                         activities (VAS)




                                                                                                             44

				
DOCUMENT INFO