Appendix 2

APPENDIX II

TREATMENT OF WHIPLASH ASSOCIATED DISORDERS
SUMMARY OF ACCEPTED RANDOMIZED CONTROLLED TRIALS

Reference Quebec
Classification Time Since
MVC at Entry Treatments (n) Analyzed Outcome
Time Outcome
Measure Outcome
Results

McKinney⁶⁰ 1, 2 (3?)
Excluded cervical fracture, dislo-cation, previous degenerative disease, previous whiplash.
< 72 hrs. after
MVC
a. prescribed rest 10-14 days, analgesics, soft collar; advice to activate after 2 weeks.
b. Physical therapy 3/wk x 6 wks: Maitland mobilization in combination with individually determined modalities, includ-ing heat/cold applications, traction, diathermy, hydro-therapy, analgesics and soft collar PRN. Advice on home exercise, posture, minimize reliance on soft collars.

c. Program of home exercises; instruction (verbal and written) re: relaxation methods, posture; advice to minimize reliance on analgesics and soft collar.
(33)
(71)

(66)
1 mo
2 mos
Pain: VAS-10
(median)

ROM: lateral

flexion

(mean degrees)
Median Pain Score
0 1 mo 2 mo

a. 5.60 4.97 3.00

b. 5.32 3.28* 1.94*

c. 5.3 3.37* 1.82*

Mean (sd) ROM

0 1 mo 2 mo

a. 44(15) 42(19) 55(15)

b. 46(19) 53(20)* 64(13)*

c. 47(21) 54(20)* 64(13)*

*Group b, c vs. a: p<.01

McKinney⁶¹ " " a. "
b. "

c. "
(26)
(54)

(48)
2 yrs Self-reported symptoms Number (%) Asymptomatic
a. 14 (54)

b. 30 (56)

c. 37 (73)*

*c vs. a, b: p=.02

APPENDIX II

TREATMENT OF WHIPLASH ASSOCIATED DISORDERS
SUMMARY OF ACCEPTED RANDOMIZED CONTROLLED TRIALS

Reference Quebec
Classification Time Since
MVC at Entry Treatments (n) Analyzed Outcome
Time Outcome
Measure Outcome
Results

Mealy⁶² 1, 2, (3?)
excluded cervical fractures
"acute" a. ice first 24 hrs, analgesics PRN, Maitland mobilization, heat, daily cervical exercises.
b. analgesics PRN, soft collar, prescribed rest 2 wks, gradual activation afterward.
(31)
(30)
4 wks
8 wks
Pain: VAS-10
ROM: total mobility score
Pain Mean (sd)
0 4 wks 8 wks

a. 5.7(2.4) 2.9(3.2)* 1.7(2.4)*

b. 6.4(2.3) 5.1(2.6)* 3.9(3.2)*

ROM Score Mean(sd)

0 4 wks 8 wks

a 19.9(9.7) 29.0(11.8)34.1(8.4)*

b.25(11.9)) 27.6(11.5)29.6(8.8)*

*Group a vs b: p<.05

Brodin^8,9 **Not applicable.
Neck pain without signs of nerve root compression; with reduced ROM
Symptoms dura-tion 0-5+ years (mechanism of in-jury not reported) a. analgesia 3 wks, wait for treatment
b. analgesic 3 wks; "mock" therapy 3/wk x 3 wks: super-ficial massage, slight traction, electrical stimulation; 3 hrs education

c. as b. above, plus Stoddard manual mobilization 3/wk x 3 wks
(23)
(17)

(23)
3 wks
4 wks
ROM increase >30E
Pain: VAS-10
Pain n(%)
Slight/

None Moderate Increased

a. *5(22) 13(56) 5(22)

b. *2(12) 13(77) 2(12)

c. *11(48) 11(48) 1( 4)

3 wks ROM increase >30E

n(%)

a. 7(30)

b. 6(35)

c. 15(65%)**

* group c vs. a, b: p<.05

APPENDIX II

TREATMENT OF WHIPLASH ASSOCIATED DISORDERS
SUMMARY OF ACCEPTED RANDOMIZED CONTROLLED TRIALS

Reference Quebec
Classification Time Since
MVC at Entry Treatments (n) Analyzed Outcome
Time Outcome
Measure Outcome
Results

Cassidy¹³ Neck pain excludes neurologic signs. 31% MVC Pain duration
<1 wk. to 6 mos.
a. single manipulation
b. single manual mobilization (Bourdillon & Day)
(52)
(48)
Base-line, Immed.post-treat-ment Pain
NRS-101

ROM: flexion/ extension rotation, lateral flexion
Pain Mean (sd)
a b

Baseline 38(26) 31(20)

Immed 20(21) 21(21)

Change 17(20) 11(15)

ROM

No differences between groups

Zylbergold¹²² Not applicable. Neck pain, mixed diagnoses. 13% neck strain. Age <70 yrs. Included radicular pain. Excluded prior neck surgery, RA, osteoporosis. Not reported. a. Static traction, neck care, moist heat, program of neck exercises. 2/wk x 6 wks.
b. Intermittent traction, neck care, moist heat, program of neck exercises 2 wk x 6 wks.

c. Manual traction, neck care, moist heat, program of neck exercises 2/wk x 6 wks.

d. Neck care, moist heat, pro-gram of neck exercises (con-trol) 2/wk x 6 wks.
(25)
(25)

(25)

(25)
Base-line (Pre)
Dis-charge (Post)
Pain: McGill present intensity.
ROM (degrees), F. Flexion, Ext, R. Rot., L. Rot., R. Flex., L. Flex
Pain Change Mean (sd)
All Traction Control

-1.27(0.97) -0.88(1.17)

ROM Change Mean (sd)

All

Traction Control

F.Flex 17.8(15.9)10.6(16.1)*

Ext. 9.6(11.2) 13.6(13.2)

R. Rot. 18.4(17.2)10.0(18.7)*

L. Rot. 10.3(17.1) 16.9(16.7)

R. Flex. 12.2( 9.7) 10.2(10.8)

L. Flex. 11.0(12.5) 11.8(11.6)

*p<0.05

APPENDIX II

TREATMENT OF WHIPLASH ASSOCIATED DISORDERS
SUMMARY OF ACCEPTED RANDOMIZED CONTROLLED TRIALS

Reference Quebec
Classification Time Since
MVC at Entry Treatments (n) Analyzed Outcome
Time Outcome
Measure Outcome
Results

Foley-Nolan²⁷ 1, 2 (3?)
Excluded impaired reflexes indicative of cervical root lesion.f
<72 hrs. a. 8hr/day x 12 wks Soft collar with active PEMT; NSAIDS PRN; advice to mobilize neck hourly; addition of physiotherapy at 4 wks at patient request.
b. 8hr/day x 12 wks Soft collars with Sham PEMT (control); other treatment as in a.
(20)
(20)
Base-line
2 wks

4 wks

12 wks
Pain: VAS-10
ROM: Total mobil-ity score (0-6 range). Analgesic intake.
Pain (median)
Base

line 2 wk 4 wk 12 wk

a. 6.8 3.8* 2.5* 1.5

b. 6.3 6.0 5.0 2.2

ROM (median)

Base

line 2 wk 4 wk 12 wk

a. 2.8* 3.0 4.0 4.5*

b. 3.7 3.5 3.3 4.0

Daily number analgesics

(median)

Base

line 2 wk 4 wk 12 wk

a. 5.0 3.5* 2.5^* 0^*

b. 6.0 6.0 5.0 1.5

*Group a vs. b: p<.05

APPENDIX II

TREATMENT OF WHIPLASH ASSOCIATED DISORDERS
SUMMARY OF ACCEPTED RANDOMIZED CONTROLLED TRIALS

Reference Quebec
Classification Time Since
MVC at Entry Treatments (n) Analyzed Outcome
Time Outcome
Measure Outcome
Results

Byrn¹¹ 1,2 (3?) 4-6 years a. subcutaneous sterile water trigger point injections x 2 months as required
b. subcutaneous sterile saline trigger point injections x 2 months as required(Control)
(20)
(20)
Base-line Immed.
1 mo.

3 mos.

8 mos.
Pain: VAS-10
ROM: Sum score
Pain (mean)
a b

Baseline 4.0 3.6

Change----------------------

Immed 0.8* 2.0*

1 mo. 2.1 3.4

3 mos. 2.3* 4.0*

8 mos. 2.4* 4.7*

ROM (mean)

a b

Baseline 288 291

Change----------------------

Immed +54* +23

1 mo. +36* +5

3 mos. +39* +6

8 mos. +20* -11

*Group a vs. b: p<.05

Barnsley³ painful cervical
zygapophysial

joint pain after

whiplash injury
> 3 months a. single intraarticular injection 1.0 ml bupivacaine (0.5 percent) (Control)
b. single intraarticular injection 1.0 ml betamethasone (5.7 mg) (Corticosteroids)

Both groups: usual analgesics and physiotherapy
(20)
(21)
Base-
line

1, 4, 6, 8, 16, 20 weeks

base-line 2, 12 weeks
Primary outcome: estimate time to return to 50% of baseline pain
Other outcome: VAS

McGill
Median time to return to 50% of baseline pain
a (control)3.5 days

b (corticosteroid) 3 days*

*N.S., p=.42

APPENDIX II

TREATMENT OF WHIPLASH ASSOCIATED DISORDERS
SUMMARY OF ACCEPTED RANDOMIZED CONTROLLED TRIALS

Reference Quebec
Classification Time Since
MVC at Entry Treatments (n) Analyzed Outcome
Time Outcome
Measure Outcome
Results

Hong⁴² Not applicable. Chronic neck pain. Mechanism not reported. Pain duration
>1 year
a. Magnetic necklace 24 hr/day x 3 wks.
b. Non-magnetic necklace 24 hr/day x 3 wks (control)
(27)
(25)
Base-line
3 wks
Pain:
intensity (0-4) frequency (0-4)
Pain Intensity Mean (sd)
Baseline 3 wks

a. 3.1(0.5) 2.7(0.7)

b. 2.8(0.6) 2.6(0.6)

Pain Frequency Mean (sd)

Baseline 3 wks

a. 2.9(0.6) 2.5(0.6)

b. 2.8(0.6) 2.5(0.7)