Table 1

Results of literature review: evidence statements, rating, and linking

TopicEvidence statementRatingReferences
C=consistent evidence; B=balance of evidence; L=limited evidence.
BiomechanicsB1Forces involved in road traffic accidents can be sufficient to potentially damage spinal structures; intervertebral discs, zygapophysial joints, muscles, ligaments.C9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20
B2Most whiplash injuries involve only the soft tissues.C21, 22, 23, 24
B3The threshold for tissue damage is a change in velocity of the order of 10-15 km/h (acceleration levels of around 3-4 g).C20, 25, 26, 27
B4The threshold for symptom generation is a change in velocity of the order of 4-8 km/h.B14, 28, 29
B5Acceleration perturbations of daily living can be greater than those in some vehicle accidents.L 30
B6In some cases, compression may be the most significant force affecting the zygapophysial joints; zygapophysial joints may be important in understanding chronic symptoms.C12 , 15, 19, 31, 32, 33
B7Biomechanical analyses should include in vivo studies in order to take account of muscle forces.B34, 35, 36, 37
B8Head restraints influence the type and severity of injury.B38, 39, 40, 41, 42, 43, 44, 45
B9Head rotated or side-bent at time of injury predicts a poorer prognosis.C46, 47, 48, 36
EpidemiologyE1Chronic symptoms after whiplash have similar prevalence to chronic neck pain in the general population.C49, 50
E2Symptom status at three months predicts status at 2 years (or more).C51, 52, 53
E3High prevalence of multiple complaints in those with chronic WAD.B54, 55
E4Higher 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.C46, 56, 57, 58, 59, 60, 61, 62, 63
E5Reported symptoms may be more severe after a second whiplash injuryL 64
E6In societies with no litigation and/or low therapeutic involvement WAD is short lived, with little or no link to chronic symptoms.C65, 66, 67, 68, 69
ClinicalC1Clinical history and examination are important to determine the WAD Grade, but add little to identifying the source of pain or its prognosis.C11, 70, 71, 72
C2Clinical outcome at 2 years can be predicted at 3 months.C51, 52, 53
C3Non-physical factors are important in the development of chronicityC57, 73, 74, 75, 76, 77, 78
C4Most 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%.C70, 79, 80
C5There is considerable individual variability in response to the accident and to symptoms.B14, 26, 29, 55, 81
C6Generalised hyper-excitability, CNS sensitisation, and muscular dysfunction have been hypothesised in chronic whiplash patients.C22, 82, 83, 84
InvestigationIn1MRI is generally unhelpful except where surgery planned.B85, 86
In2MRI shows high levels of abnormalities in normal, asymptomatic people – particularly age related changes.C87, 88, 89
In3Pre-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.B46, 87, 90
In4Radiographs considered unnecessary for Grades 0-1; advised for Grades II-III; usually negative and can highlight non-relevant findings.C5, 6, 91, 92
PsychologyP1Road traffic accident may trigger emotional and/or cognitive changes.C93, 94, 95, 96
P2Psychological disturbance may develop in the first three months as a consequence of symptoms.C51, 81, 97, 98
P3Expectation, amplification, and attribution are important in development of chronic pain and disability.B99, 100
P4WAD symptoms can be associated with illness behaviour.B6, 65, 92
P5Specific coping strategies may be beneficial.L 101
P6Psychological factors, such as anxiety, catastrophising, depression, and fear avoidance, have a significant influence on the clinical picture and on outcomes (including employment status).C102, 103, 104, 105
P7Recovery from WAD symptoms parallels improvement of cognitive disturbances.C106, 107, 108
ModelsM1Biopsychosocial model applies: similar to other musculoskeletal pain.C100, 109, 110, 111, 112, 73
M2An injury event does occur; with potential for some tissue damage, even if the precise structure cannot be identified.B9, 12, 18, 113
M3Chronic symptoms developing after whiplash injury are related closely to the presence of secondary biopsychosocial influences.B73, 99, 111, 114
M4Whiplash may be conceptualised as a risk factor for cervical symptoms rather than a discrete disease entity.L 115
TreatmentT1Faster recovery with return to pre-accident activities as soon as possible.C5, 6, 116
T2Active treatment is the most effective approach, with the corollary that rest is detrimental.C6, 117, 118, 78, 119, 120
T3Collars not helpful (grade I, II, and III); certainly beyond 72 hours.C5, 6, 121
T4Simple pain control is advantageous for musculoskeletal disorders, including WAD.B5, 6
T5Psychosocial interventions, including cognitive behavioural therapy, are helpful for management of musculoskeletal disorders, including WAD.C122, 123, 124, 125, 126
T6Manual therapy (mobilisation and/or manipulation) helpful in the early stages of WAD.C6, 127, 128, 129, 130, 131, 132, 133
T7Self exercises helpful for early recovery.C6, 78, 134
T8Traditional physical therapy modalities have limited effect.B6, 135
T9Over-medicalisation may contribute to chronic symptoms.B112, 136, 137
T10Radiofrequency neurotomy can reduce symptoms related to zygapophysial joints in chronic WAD.L138, 139
T11Antidepressants may relieve pain in chronic WADL97, 140
EducationThere is an absence of scientific information on educational interventions for WAD: these statements are mostly from other musculoskeletal literature.
Ed1Guidelines stress that information and advice is important in early management.B5, 6
Ed2Patients want and appreciate written information.C126, 141, 142, 143, 144, 145
Ed3Readability, understand-ability, acceptability, and inclusion of practical advice are important elements for booklets.C4, 146, 147
Ed4Innovative 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).C148, 149, 150, 151, 152, 153
Ed5Patients retain knowledge from health educational booklets. Men may be less likely to read information.C143, 154, 155, 156
Social policyS1Economic 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.C137, 157, 158, 159, 160, 161, 162
S2Ill directed or blanket investigations and treatment may contribute to illness behaviourL 136
S3There 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.C5, 159, 163