Results of literature review: evidence statements, rating, and linking
| Topic | Evidence statement | Rating | References | |
|---|---|---|---|---|
| C=consistent evidence; B=balance of evidence; L=limited evidence. | ||||
| Biomechanics | B1 | Forces involved in road traffic accidents can be sufficient to potentially damage spinal structures; intervertebral discs, zygapophysial joints, muscles, ligaments. | C | 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 |
| B2 | Most whiplash injuries involve only the soft tissues. | C | 21, 22, 23, 24 | |
| B3 | The threshold for tissue damage is a change in velocity of the order of 10-15 km/h (acceleration levels of around 3-4 g). | C | 20, 25, 26, 27 | |
| B4 | The threshold for symptom generation is a change in velocity of the order of 4-8 km/h. | B | 14, 28, 29 | |
| B5 | Acceleration perturbations of daily living can be greater than those in some vehicle accidents. | L | 30 | |
| B6 | In some cases, compression may be the most significant force affecting the zygapophysial joints; zygapophysial joints may be important in understanding chronic symptoms. | C | 12 , 15, 19, 31, 32, 33 | |
| B7 | Biomechanical analyses should include in vivo studies in order to take account of muscle forces. | B | 34, 35, 36, 37 | |
| B8 | Head restraints influence the type and severity of injury. | B | 38, 39, 40, 41, 42, 43, 44, 45 | |
| B9 | Head rotated or side-bent at time of injury predicts a poorer prognosis. | C | 46, 47, 48, 36 | |
| Epidemiology | E1 | Chronic symptoms after whiplash have similar prevalence to chronic neck pain in the general population. | C | 49, 50 |
| E2 | Symptom status at three months predicts status at 2 years (or more). | C | 51, 52, 53 | |
| E3 | High prevalence of multiple complaints in those with chronic WAD. | B | 54, 55 | |
| E4 | Higher risk of persisting symptoms in some groups: eg, women, older patients, high level of symptoms at onset, high prevalence of pre-traumatic headache, greater number of symptoms, degenerative changes on rdiography. | C | 46, 56, 57, 58, 59, 60, 61, 62, 63 | |
| E5 | Reported symptoms may be more severe after a second whiplash injury | L | 64 | |
| E6 | In societies with no litigation and/or low therapeutic involvement WAD is short lived, with little or no link to chronic symptoms. | C | 65, 66, 67, 68, 69 | |
| Clinical | C1 | Clinical history and examination are important to determine the WAD Grade, but add little to identifying the source of pain or its prognosis. | C | 11, 70, 71, 72 |
| C2 | Clinical outcome at 2 years can be predicted at 3 months. | C | 51, 52, 53 | |
| C3 | Non-physical factors are important in the development of chronicity | C | 57, 73, 74, 75, 76, 77, 78 | |
| C4 | Most common symptoms on presentation: neck pain ∼100%; neck stiffness ∼70%; headache 50-80%; low back pain ∼60%; shoulder pain 40-75%; visual disturbance/dizziness 10-50%. | C | 70, 79, 80 | |
| C5 | There is considerable individual variability in response to the accident and to symptoms. | B | 14, 26, 29, 55, 81 | |
| C6 | Generalised hyper-excitability, CNS sensitisation, and muscular dysfunction have been hypothesised in chronic whiplash patients. | C | 22, 82, 83, 84 | |
| Investigation | In1 | MRI is generally unhelpful except where surgery planned. | B | 85, 86 |
| In2 | MRI shows high levels of abnormalities in normal, asymptomatic people – particularly age related changes. | C | 87, 88, 89 | |
| In3 | Pre-existing abnormalities on MRI (mainly age related changes), whilst not specifically related to the neck injury, may be a risk factor for longer pain duration. | B | 46, 87, 90 | |
| In4 | Radiographs considered unnecessary for Grades 0-1; advised for Grades II-III; usually negative and can highlight non-relevant findings. | C | 5, 6, 91, 92 | |
| Psychology | P1 | Road traffic accident may trigger emotional and/or cognitive changes. | C | 93, 94, 95, 96 |
| P2 | Psychological disturbance may develop in the first three months as a consequence of symptoms. | C | 51, 81, 97, 98 | |
| P3 | Expectation, amplification, and attribution are important in development of chronic pain and disability. | B | 99, 100 | |
| P4 | WAD symptoms can be associated with illness behaviour. | B | 6, 65, 92 | |
| P5 | Specific coping strategies may be beneficial. | L | 101 | |
| P6 | Psychological factors, such as anxiety, catastrophising, depression, and fear avoidance, have a significant influence on the clinical picture and on outcomes (including employment status). | C | 102, 103, 104, 105 | |
| P7 | Recovery from WAD symptoms parallels improvement of cognitive disturbances. | C | 106, 107, 108 | |
| Models | M1 | Biopsychosocial model applies: similar to other musculoskeletal pain. | C | 100, 109, 110, 111, 112, 73 |
| M2 | An injury event does occur; with potential for some tissue damage, even if the precise structure cannot be identified. | B | 9, 12, 18, 113 | |
| M3 | Chronic symptoms developing after whiplash injury are related closely to the presence of secondary biopsychosocial influences. | B | 73, 99, 111, 114 | |
| M4 | Whiplash may be conceptualised as a risk factor for cervical symptoms rather than a discrete disease entity. | L | 115 | |
| Treatment | T1 | Faster recovery with return to pre-accident activities as soon as possible. | C | 5, 6, 116 |
| T2 | Active treatment is the most effective approach, with the corollary that rest is detrimental. | C | 6, 117, 118, 78, 119, 120 | |
| T3 | Collars not helpful (grade I, II, and III); certainly beyond 72 hours. | C | 5, 6, 121 | |
| T4 | Simple pain control is advantageous for musculoskeletal disorders, including WAD. | B | 5, 6 | |
| T5 | Psychosocial interventions, including cognitive behavioural therapy, are helpful for management of musculoskeletal disorders, including WAD. | C | 122, 123, 124, 125, 126 | |
| T6 | Manual therapy (mobilisation and/or manipulation) helpful in the early stages of WAD. | C | 6, 127, 128, 129, 130, 131, 132, 133 | |
| T7 | Self exercises helpful for early recovery. | C | 6, 78, 134 | |
| T8 | Traditional physical therapy modalities have limited effect. | B | 6, 135 | |
| T9 | Over-medicalisation may contribute to chronic symptoms. | B | 112, 136, 137 | |
| T10 | Radiofrequency neurotomy can reduce symptoms related to zygapophysial joints in chronic WAD. | L | 138, 139 | |
| T11 | Antidepressants may relieve pain in chronic WAD | L | 97, 140 | |
| Education | There is an absence of scientific information on educational interventions for WAD: these statements are mostly from other musculoskeletal literature. | |||
| Ed1 | Guidelines stress that information and advice is important in early management. | B | 5, 6 | |
| Ed2 | Patients want and appreciate written information. | C | 126, 141, 142, 143, 144, 145 | |
| Ed3 | Readability, understand-ability, acceptability, and inclusion of practical advice are important elements for booklets. | C | 4, 146, 147 | |
| Ed4 | Innovative patient educational material (eg, The Back Book), that presents unambiguous messages focused on changing detrimental beliefs and attitudes can shift beliefs whilst having a beneficial effect on clinical outcomes, and may reduce care seeking and work loss. (However, more traditional booklets may not have the same effect). | C | 148, 149, 150, 151, 152, 153 | |
| Ed5 | Patients retain knowledge from health educational booklets. Men may be less likely to read information. | C | 143, 154, 155, 156 | |
| Social policy | S1 | Economic incentives, changes to rules governing eligibility, and moves to no fault compensation can influence reporting rates and societal costs; these issues may be confounded with reduced contact with therapeutic and legal communities. | C | 137, 157, 158, 159, 160, 161, 162 |
| S2 | Ill directed or blanket investigations and treatment may contribute to illness behaviour | L | 136 | |
| S3 | There are high costs to society in many countries; in common with other musculoskeletal conditions, the majority of the costs are incurred by the chronic cases. | C | 5, 159, 163 | |