IOS Press A systematic review of chiropractic management ......WAD is needed to enable persons to...

Work 35 (2010) 369–394 369DOI 10.3233/WOR-2010-0996IOS Press

A systematic review of chiropracticmanagement of adults withwhiplash-associated disorders:Recommendations for advancingevidence-based practice and research

Lynn Shawa, Martin Descarreauxb, Roland Bryansc,∗, Mireille Duranleaud, Henri Marcouxe,Brock Potterf , Rick Rueggg, Robert Watkinh and Eleanor Whitei

aFaculty of Health Sciences, School of Occupational Therapy, University of Western Ontario, London, ON, CanadabDepartement de Chiropratique, Universite du Quebec a Trois Rivieres, Trois Rivieres, QC, CanadacChairman, Guidelines Development Committee (GDC), Chiropractor, Clarenville, NL, CanadadChiropraticienne, Montreal, QC, CanadaeChiropractor, Winnipeg, MB, CanadafChiropractor, North Vancouver, BC, CanadagCanadian Memorial Chiropractic College, Toronto, ON, CanadahHIV and Aids Legal Clinic Ontario, Toronto, ON, CanadaiChiropractor, Markham, ON, Canada

Received 13 January 2010

Accepted 16 January 2010

Abstract. The literature relevant to the treatment of Whiplash-Associated Disorders (WAD) is extensive and heterogeneous.Methods: A Participatory Action Research (PAR) approach was used to engage a chiropractic community of practice andstakeholders in a systematic review to address a general question: ‘Does chiropractic management of WAD clients have an effecton improving health status?’ A systematic review of the empirical studies relevant to WAD interventions was conducted followedby a review of the evidence. Results: The initial search identified 1,155 articles. Ninety-two of the articles were retrieved,and 27 articles consistent with specific criteria of WAD intervention were analyzed in-depth. The best evidence supporting thechiropractic management of clients with WAD is reported. Further review identified ways to overcome gaps needed to informclinical practice and culminated in the development of a proposed care model: the WAD–Plus Model. Conclusions: There isa baseline of evidence that suggests chiropractic care improves cervical range of motion (cROM) and pain in the managementof WAD. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at thistime. The WAD-Plus Model has implications for use by chiropractors and interdisciplinary professionals in the assessment andmanagement of acute, subacute and chronic pain due to WAD. Furthermore, the WAD-Plus Model can be used in the future studyof interventions and outcomes to advance evidence-based care in the management of WAD.

Keywords: Pain, neck, treatment, manipulation, assessment

∗Address for correspondence: Dr. Roland Bryans, The CCA/CFCREAB Clinical Guidelines Project, 39 River Street, Toronto,Ontario, Canada, M5A 3P1. E-mail: [email protected].

1. Introduction

Whiplash-Associated Disorders (WAD) are a majorhealth problem that disrupt the daily and work lives of

1051-9815/10/$27.50 2010 – IOS Press and the authors. All rights reserved

370 L. Shaw et al. / A systematic review of chiropractic management of adults with whiplash-associated disorders

people around the world [11]. For people experiencingWAD, one of the primary concerns is the debilatorynature of pain. Thus, knowledge that can support theefficient and effective management and recovery fromWAD is needed to enable persons to resume mean-ingful participation in family and work life, as wellas support clinicians, such as chiropractors, in deliv-ering evidence-based approaches to the managementof WAD. The chiropractic community has traditional-ly provided leadership in the interventions that supportrecovery and the management of pain for those withWAD.

Historically, the profession of chiropractic has con-tributed to the development of a knowledge base sup-porting the treatment and management of WAD. Pub-lished documents, inquiries, and expert knowledgehave provided a backdrop for WAD treatment and care.For instance, several texts developed by chiropractorsinform the education of new chiropractors in the man-agement of WAD [9,21,41,48]. Moreover, these textsare widely used within the profession as they providethe basis for understanding the etiology of WAD, aswell as the assessment, evaluation and treatment deci-sions underscoring chiropractic practice. Experiential-ly, the outcome of treatment of WAD is well knownin the field of chiropractic and to clients. However,there is a new factor promoting a paradigm shift in thebody of knowledge used to guide the management ofWAD: that of evidence-based knowledge. This changeis a reflection of a growing expectation and subsequenttension in the health disciplines, including chiropractic,to adopt and use research-based knowledge to informtreatments and decision-making in practice. The pro-fession and discipline of chiropractic has responded tothis expectation through envisioning and committing toa sustainable process for knowledge exchange, synthe-sis and transfer to support the advancement and use ofevidence in practice through the development of guide-lines for practice. As part of this ongoing process, theClinical Practice Guidelines Task Force (CPG TF) andthe Guidelines Development Committee (GDC), iden-tified the need to advance evidence-based managementof WAD. Moreover, this approach is moving the disci-pline toward integration of research evidence, with pro-fessional expertise and client knowledge in decision-making that is consistent with Sackett’s [57] definitionof evidence-based practice in the medical and healthdisciplines. Such an approach to evidence recognizesand values the synthesis of knowledge sources need-ed in clinical decision-making when addressing theidiosyncratic presentation of clinical and non-clinicalfindings in caring for clients with WAD.

The available clinical literature on the treatment ofWAD is extensive and chiropractors, as well as physicaltherapists, physicians, surgeons, etc inform the contri-butions to this knowledge base. However, there is a lackof synthesis of the evidence needed to inform clinicalpractice guidelines for the chiropractic management ofWAD and the resumption of pre-injury activities suchas work. This gap was recognized by the CPG TF andthe GDC of the chiropractic community in Canada whoin turn provided the impetus for developing a processthat involved stakeholders (board members of the pro-fessional associations, the national professional asso-ciation the Canadian Chiropractic Association (CCA)and the Canadian Federation of Chiropractic Regula-tory, Education and Accrediting Boards (CFCREAB),interprofessional and the chiropractic community suchas specialty colleges and organizations interested in thedevelopment of Clinical Practice Guidelines, to estab-lish and update clinical guidelines for the chiropracticmanagement of WAD based on the best available evi-dence. This paper outlines this process and the system-atic review conducted to inform clinical guidelines inthe chiropractic management of WAD.

2. Background and literature on chiropracticmanagement of WAD

In this paper, WAD is defined as a clinical problemin adult whiplash trauma that occurs with sudden ac-celeration or deceleration of the head and neck rela-tive to other parts of the body, typically during vehiclecollisions or other mishaps. Signs and symptoms ofwhiplash injury are collectively described as WAD [68].Whiplash-related symptoms differ from treating otherforms of cervical pain as pain outcomes differ betweenWAD and non-WAD clients [2]. For instance symp-toms may include, but are not limited to, neck pain,musculoskeletal signs (such as hyperalgesia,movementloss, neck stiffness, kinaesthetic deficits and balanceloss) [69] deafness,dizziness, tinnitus, headache, mem-ory loss, dysphagia and temporomandibular pain [68].

Clients with WAD are graded by the severity of signsand symptoms and the classification of whiplash injuryby WAD grade is used routinely in clinical practice toprovide an understanding of the condition [68]. Forinstance, clients with WAD are graded by the severityof signs and symptoms from Grade 0 (no complaintsor physical signs after a whiplash event; no WAD) toGrade 4 (fracture or dislocation). Increasing gradesof WAD from WAD-1 through WAD-4 define an in-

L. Shaw et al. / A systematic review of chiropractic management of adults with whiplash-associated disorders 371

creasing severity and differential presentation of signsand symptoms. From the standpoint of treatment, eachWAD grade is distinct and mutually exclusive. Thesegrades are used to provide a universal understanding bya broad range of users, researchers, health care profes-sionals, insurance and legal systems.

Many clients with WAD recover quickly and com-pletely; however, chronic symptoms or disability affectothers (19–60%) [61]. Up to half of WAD-1 or WAD-2clients suffer neck pain and disability 6 months afterinjury (i.e. chronic WAD) [30], and almost a quarterof these clients remain symptomatic after 1 year [11].Chronic WAD accounts for almost half of all whiplash-related costs such as treatment and lost wages [30,54].Consequently, a foremost treatment goal for WAD isto prevent the progression of acute to chronic symp-toms. Yet, the research evidence supporting interven-tions used to achieve these outcomes is missing andthis gap underpins some of the current tensions in ad-vancing evidence-based practice in WAD care. Histor-ically, there were few chiropractors funded to do re-search. This is changing. There is recent movement to-wards university-based chiropractic research chairs tolead research efforts to bridge the research to practicegaps.

The most common chiropractic intervention is theadjustment [15], which usually involves High VelocityLow Amplitude (HVLA) manipulation. The practice ofspinal manipulation (such as HVLA) is an interventionthat dates back to time of the Egyptians and Romansand on up through the centuries to the time of bonesetters and finally chiropractors in the late 1800s. Assuch, the adjustment (or HVLA manipulation), holdsits roots not so much in science but in traditional usagemuch like the use of heat and ice therapies. More re-cently, chiropractic extrapolates evidence on HVLA forthe treatment of WAD from the use of HVLA to treatother types of neck pain. From an “evidence based”perspective, previous work [2,27] suggests that man-ual therapy (SMT [HVLA] or mobilization) and ex-ercise interventions are more effective than no treat-ment, sham or some other alternative interventions forneck pain. In the absence of strong evidence to guideclinicians regarding the use of HVLA for WAD, chiro-practors have chosen HVLA based on tradition, clin-ical experience and available data on neck pain treat-ments. A study by Woodward et al. [77] used a retro-spective chart review of 28 chronic whiplash clients, 27of whom had intrusive or disabling symptoms. Chiro-practic care (HVLA manipulation, proprioceptive neu-romuscular facilitation, cryotherapy) initiated an aver-

age of 16 months after injury was associated with im-provement for 26 clients. A limitation of this study isthat control subjects were not available for comparison.Beyond this, the extent of other evidence on HVLAmanipulation for WAD is unknown.

Pain is a leading symptom of WAD and is addressedby almost all published studies. The International As-sociation for the Study of Pain (IASP) defines pain as“an unpleasant sensory and emotional experience as-sociated with actual or potential tissue damage” [32].Acute, subacute, and chronic pain are defined clinical-ly based on time since injury. The IASP operational-ly defines pain lasting more than 3 months as chronicpain [46]. Often, there are few physical abnormalitiesfor subjects whose pain persists for 3 months or longer.By inference, acute pain lasts less than 3 months andsubacute pain is used to refer to pain that has persistedfor longer than a brief period but not yet 3 months [47].An actual dividing line between acute and subacute andbetween subacute and chronic symptoms is unique toeach client’s clinical situation. Given the current litera-ture on pain, the following definitions and time periodswere used to categorize pain in this paper: acute (0–7days), subacute (1 week to 3 months) and chronic (morethan 3 months). Treatment of pain in the managementof WAD varies and more effort is needed to providea comprehensive understanding of evidence-based ap-proaches that chiropractors can use to ameliorate painand improve health outcomes for persons with WAD.

Others in the global health community are also recog-nizing and responding to the need to promote researchin neck pain. The recent emergence of documents suchas the Bone and Joint Decade 2000–2010 Neck PainTask Force (BJD TF) papers [27] underscores these ef-forts. In other approaches, insurance claims data arebeing analyzed to understand the prognosis of whiplashinjuries [13,14].

The literature search and analysis in this paper aimedto help move evidence-based knowledge into the handsof chiropractors to support the chiropractic manage-ment of WAD. The synthesis of the evidence supportsboth evidence-informed and GDC consensus recom-mendations to improve health outcomes. Based uponthe evidence, recommendations are also made to ad-vance future research. The main question underscor-ing this systematic review is: ‘Does chiropractic man-agement of WAD clients have an effect on improvinghealth status?’ Chiropractic management of WAD inthis review was determined by the CPG TF and theGDC to be inclusive of all potential treatment modali-ties used by manual practitioners. Thus, the literature


search strategy, was not restricted to treatment modal-ities delivered by chiropractors only, rather a wide netwas cast to include treatments that may be administeredin chiropractic care, though may be delivered in thecontext of care by other healthcare professionals in aspecific research study (e.g. use of exercise regimensto treat WAD).

3. Methods

Traditionally, systematic reviews of the literatureare conducted to inform health care decision-makinggrounded in research evidence. The end-users of re-views, such as chiropractors, are often left with thedaunting task of interpreting the relevance of researchevidence to a particular area of practice within a field.In the Canadian chiropractic community, a strategic ap-proach to evidence synthesis was envisioned that adopt-ed a comprehensive knowledge transfer process to sup-port the accessibility and uptake of evidence by end-users [63] through the development of best evidencepractice guidelines. This approach used in chiropracticis comprehensive and attests to the commitment of theprofession to advance evidence-based practice throughengaging a knowledge exchange and transfer processthat emphasizes and supports the movement of researchknowledge into practice [32,40]. The involvement ofthe CPG TF and GDC is also consistent with the knowl-edge transfer literature [33] that suggests that the moreengaged health care professionals are in the researchprocess the more likely evidence will be transferredand applied in client care. Further to this, the devel-opment of practice guidelines will afford a more effi-cient and sustainable mechanism to bridge the gap be-tween research knowledge and its use in practice by allchiropractors.

In keeping with a philosophy of participation andthe need to develop relevant processes of dissemina-tion consistent with knowledge use in practice, a par-ticipatory action research (PAR) approach [67] under-pinned the processes of this systematic review and theknowledge transfer efforts. The PAR approach reflectsa cycle of defining the problem; planning; data gen-eration; data analysis and interpretation; action; andevaluation.

– Defining the problem: The CPG TF identified theneed to establish a baseline of evidence on chiro-practic care in the management of WAD.

– Planning: The GDC then planned for and adaptedsystematic processes for the extraction, review andanalysis of data using source evidence review andbest evidence synthesis [64].

– Data generation: A systematic review was usedto generate data. This review included steps suchas identifying scope of search, engaging expertconsultation, establishing search terms and ratio-nale, and using specific data extraction and analy-sis methods.

– Data analysis and interpretation: A multi-stepprocess was used to analyze and interpret data.A review team of contributors, who were expertswith research and clinical expertise in chiropracticand/or data synthesis, conducted a detailed sourceevidence analysis. The expert contributor reviewteam and the GDC interpreted the source evidenceand conducted the best evidence synthesis relevantto chiropractic treatment and care of WAD.

– Action: The GDC developed recommendationsfor practice, and a WAD-Plus model to promoteevidence-based practice in the management ofWAD [8].

– Evaluation: An iterative process of evaluation in-cluded consultation and feedback with the CPGTF and stakeholders on the extent to which theinformation is easy to understand and appropriatefor dissemination and use by chiropractors.

Based on the PAR approach, all participants in this pro-cess shaped the direction of this systematic review andcontributed to the emergent research processes need-ed to make sense of the evidence, to synthesize evi-dence through analysis, to generate practice recommen-dations, and to identify dissemination strategies. Thiscollaborative and consultative process led to 8 steps ofthis systematic review and synthesis. These process-es dovetailed with the three components fundamen-tal to evidence-based practice combined to inform thiswork [57]: (1) Evidence extracted from the publishedliterature about effective chiropractic care for adultswith WAD, (2) Knowledge of the client; including painhistory, culture, gender, age, socioeconomic, psycho-logical, and (3) Chiropractors’ clinical experience.

3.1. Basic steps of this systematic review

Literature searchStep 1: Define research question, scope of search

and search termsStep 2: Identify articles and key experts for articlesStep 3: Conduct literature search


Table 1

Search terms

Intervention Terms Effect; efficacy; effectiveness; and treatment outcome. Search terms to describe interventionswere: management; intervention; manipulation; rehabilitation; manual therapy; chiropractic;physical therapy; physiotherapy; client education; exercise; mobilization; and prevention.

Practice Terms Whiplash; whiplash-associated disorders; neck injury(ies); neck sprain; and neck strain

Types of treatment or treatment modalities Rest; relaxation; collar; information; instruction (active education); progressive return tonormal activities of daily living (nADL); thermotherapy; hydrotherapy; traction; massage;electrotherapy (pulsed electromagnetic therapy)[PEMF], transcutaneous electrical nerve stim-ulation [TENS], diathermy, ultrasound); supervised or unsupervised, aerobic, strengthening,endurance or kinesthetic exercise; supervised or unsupervised, passive or active mobilization;McKenzie and Maitland mobilization; high velocity, low amplitude (HVLA) manipulation;psychological support; and cognitive behavioral therapy (CBT)

Selection for relevanceStep 4: Conduct Stage 1a review: Select articles for

inclusion using abstracts and titlesStep 5: Conduct Stage 1b review: Extract articles for

inclusion using text screening, operational definitionsand inclusion criteria

Quality assessmentStep 6: Conduct Stage 2 review: Assess quality of

relevant articles

Evidence synthesis and guideline developmentStep 7: Extract and analyze treatment and health

outcome evidence and conduct synthesisStep 8: Interpret knowledge and evidence for ad-

vancing the management of WADThe rules and actions for each step in the review and

synthesis processes are outlined below. All steps in thereview processes were achieved through consensus.

3.2. Literature search (Steps 1,2,3)

Two literature searches were completed respective-ly in 2005 (including articles published in English andGerman) and 2006 (including articles published in En-glish and French) to identify intervention studies rel-evant to WAD. Three languages were included basedon the linguistic fluency of the review team mem-bers. Reviews were completed using PubMed (1966through April 2006), EMBASE, the Cumulative Indexto Nursing and Allied Health (CINAHL), the Physio-therapy Evidence Database (PEDro), PsychINFO, andthe Cochrane Library. Search terms included in this re-view are organized in Table 1. Published studies wereused as the preferred basis for recommendations, andknowledge based on clinical experience was equivalentto the lowest level of research evidence.

By stakeholder consensus as further defined by theGDC, the following therapies were excluded: acupunc-

ture, surgical procedures, invasive analgesic proce-dures including nerve blocks, neuro-ablative proce-dures, epidural blocks, facet and intramuscular injec-tions, botulinum toxin, systematic psychological inter-ventions such as cognitive or behavior therapies foranxiety or depression, and over-the-counteror prescrip-tion drugs.

Upon further consideration The CCA and CFCREABstakeholders further deemed that cognitive behaviortherapy (CBT) may be considered by chiropractors inthe context of multidisciplinary treatment. Also, re-garding CBTs, the GDC deemed that it is within thescope of chiropractic to address the client’s fears andconcerns regarding their recovery. As such these treat-ments were included in the review.

The search strategy was designed to retrieve all pub-lications excluding editorials and letters to the editor.Results were limited to adult subjects (� 18 years ofage). Manual searches of reference lists of review ar-ticles and treatment studies were also completed. Anexception to this approach involved citing recently pub-lished work from The Bone and Joint Decade 2000–2010 Neck Pain Task Force [27] (BJD TF). The workof the BJD TF was published during the preparation ofthis manuscript and the GDC considered it importantto consult this work where appropriate for the clinicalmanagement of WAD.

3.3. Selection for relevance (Steps 4 & 5)

Literature results were entered into a searchabledatabase, and relevant publications were retrieved ashard copies and evaluated. In the first stage of the re-view (1a review), articles were selected based on thescreening of abstracts and titles and in review 1b the fulltext was screened for consistency with the operationaldefinitions for chiropractic treatment, neck, adult andWAD. Two independent reviewers used these criteriaand where necessary, uncertainties were resolved by a


Table 2The Utilization of Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence

The categorization below is adapted from OCEBM levels of evi-dence. Documents at the referenced web-site were used to discrim-inate between good and poor quality studies of the same design.

The interpretation (below) of the meaning of levels of evidence (leftcolumn) is the opinion of the GDC, based on the OCEBM recommen-dation grading system.

Study type Evidence level Study resultsare . . .

You interpretresults. . .

Clinical meaning &recommendation grade

Systematic review of randomized control tri-als (RCT) with homogeneity

1a almost certain objectively Recommendations direct-ly supported by evidenceare very likely reliable andvalid.

Individual RCT (with narrow ConfidenceInterval)

1b

All or none 1c

Systematic review of cohort studies withhomogeneity

2a stronglysuggestive

objectively Recommendations directlysupported by evidence arelikely reliable and valid.

Individual cohort study, low quality RCT 2bOutcomes research, ecological studies 2cSystematic review of case-control studies(with homogeneity)

3a

Individual case-control study 3b

Case-series, poor quality cohort and case-control studies

4 suggestive objectively Recommendations directlysupported by evidence maybe reliable and valid.

Expert opinion with explicit critical ap-praisal, and based on one of physiology,bench research, first principles

5 inconclusive objectively Reliability and validity ofrecommendationsuncertain.

Studies of Levels 1–4 that are inconclusivedue to flaws in their design or analytic logic,but that present authored conclusionsOther (e.g., literature review, CPG, reviewsof reviews)

subjective extrapolation from Levels 1 to 5

third reviewer. Articles were selected for further anal-ysis if the study population included clients with WAD1 to 4, and at least one subgroup of clients received carerelevant to chiropractic practice.

Next, studies found by the first literature search weretagged with tracking numbers, and then 2 evidence ex-tractors were allocated alternately numbered studies.Other review papers were considered relevant to thisresearch only if they described systematic reviews oftreatment literature for WAD. Systematic reviews forgeneral neck pain, mechanical neck pain not attributedto whiplash, or neck pain of unknown etiology wereexcluded. Non-systematic reviews or reviews that con-founded outcome or treatment data from WAD andnon-WAD patients were excluded.

3.4. Quality assessment (Step 6)

A quality assessment of the final extracted articleswas conducted by an external review team. Papers thatfailed to distinguish treatments, outcomes, time since

injury, or data from WAD versus non-WAD clients wereexcluded. First, the evidence extractors together useda Table adapted from The Oxford Centre for Evidence-based Medicine (OCEBM) levels of evidence [2,49] tocategorize the remaining 27 studies into 5 Levels ofevidence see Table 2. Where necessary, disagreementswere resolved with the participation of a third evidenceextractor.

Next, given that the evidence included treatmentsprovided by a range of health care providers the evi-dence extractors conducted a source evidence [24,25],qualitative review process to interpret the quality andthe clinical relevance of the treatment and outcomesfor chiropractic practice. This process involved a re-view team comprised of a health care professional andtwo expert chiropractic contributors who conducted theanalysis of source evidence. This team qualitatively re-viewed each study to assess the methodological qualityof the level of evidence supporting the main outcomesof the studies and evidence benefit of health outcomesfor chiropractic. The team openly discussed the quali-


ty of the studies to achieve group consensus on ratingof the level of evidence of the study findings, reflect-ing the confidence with which the reported data couldsupport clinically relevant conclusions. The levels ofevidence (using the OCEBM see Table 2) reflecting theconfidence with which the reported data could supportclinically relevant conclusions are listed in column 5of Tables 3, 4, 5. A different three-panel clinical ex-pert review team reviewed the findings of the extractorswith minor revisions.

3.5. Evidence synthesis (Steps 7 & 8)

The heterogeneity of the interventions posed a con-siderable challenge for data synthesis. In addition,the quality of evidence did not support the statisticalpooling of outcomes data. Hence, the advancement ofthe review required additional deliberation among theGDC, the CPG TF and contributor teams to decide onthe approach to evidence analysis and synthesis. A de-cision was made to use a qualitative approach to con-duct best evidence synthesis using the results of thesource evidence [24,25] quality ratings.

3.5.1. Criteria for best evidence synthesisSlavin’s approach to best evidence [64] involves es-

tablishing a process and criteria for evaluating the qual-ity of the evidence supporting health outcomes, basedupon the quantity of evidence and the consistency offindings. The processes for establishing the qualityratings included a systematic method of extrapolation(achieved in Steps 1–6) followed by a systematic anal-ysis of source evidence [24].

3.5.1.1. Quantity and consistency of evidenceThe GDC established criteria for best evidence syn-

thesis to answer the question ‘Does chiropractic man-agement of WAD clients have an effect on improvinghealth status?’ The criteria of two or more studies of thesame quality (L4 equivalent to a low level) or greaterwere sufficient to establish a minimal level baseline forconducting best evidence synthesis. In this process ofthe review, quality ratings in column 5 of Tables 3–5were used to identify studies of the same quality (L4)or greater that consistently converged on similar out-comes across 2 or more studies. Likewise findings werereviewed for consistency within the categories of treat-ments to identify the minimum level of consistency forestablishing a baseline of best evidence synthesis. TheGDC determined the minimum level to be two or morestudies rated L4 or greater. The GDC provided expert

consensus recommendations if suggestions for practicewere warranted across studies when findings were L5or only one study was rated as L4. Following the reviewof the evidence the GDC provided recommendationsfor clinical practice or research.

3.6. Interpret knowledge and evidence for advancingthe management of WAD

In uncovering the overwhelming diversity in thetreatment approaches presented in the literature, the ex-pert contributor team and the GDC identified the needfor a framework to organize current and future findingsconsistent with clinical processes used in the manage-ment of WAD. Additional review and interpretation ofthe 27 articles and related literature relevant to the chi-ropractic management of WAD was conducted by theGDC to identify ways to address the knowledge gaps.The expert review contributor team and GDC reflectedon the WAD literature, the current baseline and gaps ofevidence identified in the systematic review, and whatfactors contributed to the gaps in the research processesin studies, as well as, inconsistencies across studies inthe literature. Through this appraisal process the GDCconstructed a framework for use in the management ofWAD and for future clinical research titled the WAD-Plus Model (see description of WAD-Plus Model insection 4.6).

4. Findings and recommendations

4.1. Literature searches

Literature searches found 1,155 citations. Eighty-nine treatment articles were selected for relevance, and24 studies were analyzed in detail [5–7,10,16,18–20,22,28,29,42,44,51–53,56,59,61,65,66,70,75,77]. Threearticles [36,50,71] identified by the BJD TF were morerecent than this guide’s literature search and underwenta quality assessment and source evidence evaluationbringing detailed study extractions to 27.

Data were extracted for synthesis from the 27 stud-ies. Studies investigating treatment interventions werecategorized into three groups based on WAD clinicalpresentation and time since injury: acute (Table 3),subacute (Table 4) and chronic (Table 5). The majorityof the 27 studies reported findings relevant to one ormore WAD grades. The primary health status outcomesreported in the treatment outcomes studies for WADwere cROM and pain. Additional health outcomes


Tabl

e3

Lite

ratu

resu

mm

ary

and

qual

ityra

tings

ofth

eev

iden

cefo

rin

terv

entio

nsfo

rac

ute

whi

plas

h

Stud

yIn

terv

entio

nsst

udie

dR

esul

tson

heal

thou

tcom

e(s)

GD

Cre

com

men

dsQ

ualit

yra

ting∗

Bor

chgr

evin

ket

al.,

1998

Mai

ntai

nnA

DL

svs

.R

est,

sick

leav

e,da

ytim

eco

llar

for

14da

ysA

t6m

onth

s1◦

anal

yses

:

–Pa

infa

ctor

/com

posi

te(i

mpr

oved

;no

grou

pdi

ffer

ence

s)

Oth

eran

alys

es:

–A

ttent

ion

Fact

ors

(Y;m

aint

ain

AD

Ls)

–T

inni

tus

(no

grou

pdi

ffer

ence

s)–

Pain

dist

ribu

tion

(Y;m

aint

ain

AD

Ls)

–Pa

indu

ring

AD

L(Y

;mai

ntai

nA

DL

s)–

Mob

ility

(no

grou

pdi

ffer

ence

s)–

VA

S(Y

;mai

ntai

nA

DL

s)–

Nec

kst

iffn

ess

(Y;m

aint

ain

AD

Ls)

–Si

ckL

eave

(no

grou

pdi

ffer

ence

s)–

Self

-rat

ings

(no

grou

pdi

ffer

ence

s)

Mai

ntai

nnA

DL

L4

Kon

gste

det

al.,

2007

Mai

ntai

nnA

DL

svs

.Day

time

colla

rfo

r14

days

vs.A

ctiv

em

obili

zatio

npr

ogra

mA

t1ye

ar1◦

anal

yses

:B

oth

grou

psim

prov

ed:

–H

eada

che

and

neck

pain

inte

nsity

(no

grou

pdi

ffer

ence

s)

2◦an

alys

es(n

ogr

oup

diff

eren

ces

repo

rted

):

–C

hang

ein

head

ache

and

neck

pain

–M

edic

atio

nus

e–

SF-3

6–

Nec

km

obili

ty

Mai

ntai

nnA

DL

sL

5

Oliv

eira

etal

.,20

06E

duca

tiona

lvid

eo,i

nfor

mat

ion/

inst

ruc-

tion

vs.I

nfor

mat

ion/

inst

ruct

ion

At1

,3an

d6

mon

ths:

1◦an

alys

es:

–Pa

in(Y

;vid

eo)

Oth

eran

alys

es:

–Pa

tient

satis

fact

ion

(Y;v

ideo

)–

Lif

ech

ange

(Y;v

ideo

)–

Wor

kday

sm

isse

d(Y

;vid

eo)

Edu

catio

nalv

ideo

orin

-per

son

info

rma-

tion

abou

tce

rvic

alst

rain

and

the

role

ofex

erci

sean

dre

laxa

tion

L5

Ferr

arie

tal.,

2005

Em

erge

ncy

dept

.us

ual

care

plus

edu-

catio

nal

pam

phle

tvs

.E

mer

genc

yde

pt.

usua

lcar

e

At2

wee

ksan

d3

mon

ths

(no

grou

pdi

ffer

ence

s):

–R

ecov

ery

outc

omes

–R

esou

rce

use

–W

ork

stat

us–

Liti

gatio

n

Rec

omm

enda

tion

agai

nstu

sing

aon

e-tim

ein

form

atio

nto

olun

less

cost

and

burd

enof

use

are

negl

igib

le

L5


Tabl

e3,

cont

inue

d

Stud

yIn

terv

entio

nsst

udie

dR

esul

tson

heal

thou

tcom

e(s)

GD

Cre

com

men

dsQ

ualit

yra

ting∗

Bri

son

etal

.,20

05E

mer

genc

yde

pt.

usua

lca

repl

used

uca-

tiona

lvi

deo

vs.E

mer

genc

yde

pt.

usua

lca

real

one

At2

4w

eeks

1◦an

alys

es:

–W

AD

sym

ptom

s(n

ogr

oup

diff

eren

ces)

2◦an

alys

es:

–C

hang

ein

pain

scor

es(Y

;vid

eo)

Edu

catio

nalv

ideo

orin

-per

son

info

rma-

tion

abou

tce

rvic

alst

rain

and

the

role

ofex

erci

sean

dre

laxa

tion

L5

Bon

ket

al.,

2000

Mul

timod

al,p

hysi

othe

rapy

vs.D

aytim

eco

llar

for

3w

eeks

,re

stvs

.U

ninj

ured

cont

rols

At3

,6an

d12

wee

ks: :

–N

eck

pain

(Y;m

ultim

odal

)–

Nec

kst

iffn

ess

(Y;m

ultim

odal

)–

Hea

dach

e(Y

;mul

timod

al)

–Sh

ould

erpa

in(Y

;mul

timod

al)

–A

rmpa

in(Y

;mul

timod

al)

–cR

OM

(Y;m

ultim

odal

atw

eek

3on

ly)

Mul

timod

al,a

ctiv

etr

eatm

ent

L4

Schn

abel

etal

.,20

04C

olla

rfo

r1

wee

kvs

.E

xerc

ise

ther

apy

(2–5

visi

tsin

first

wee

k)A

t6w

eeks

: 1◦

anal

yses

:

–Pa

inan

ddi

sabi

lity

(Y;e

xerc

ise

grou

p)

2◦an

alys

es:

–H

eada

che

(Y;e

xerc

ise

grou

p)–

Shou

lder

pain

(Y;e

xerc

ise

grou

p)–

Bac

kpa

in(n

ogr

oup

diff

eren

ces)

–L

imb

pain

(no

grou

pdi

ffer

ence

s)–

Lim

bpa

rest

hesi

a(n

ogr

oup

diff

eren

ces)

–V

isua

ldis

turb

ance

s(n

ogr

oup

diff

eren

ces)

–T

inni

tus

(no

grou

pdi

ffer

ence

s)–

Diz

zine

ss(n

ogr

oup

diff

eren

ces)

Am

ediu

mco

urse

ofun

supe

rvis

edc-

RO

Mex

erci

seL

5

Cra

wfo

rdet

al.,

2004

Col

lar

for

3w

eeks

,th

enex

erci

sevs

.B

rief

colla

rus

e,th

enex

erci

seA

t3,1

2an

d52

wee

ks:

–Pa

in(n

ogr

oup

diff

eren

ces)

–nA

DL

s(n

ogr

oup

diff

eren

ces)

–cR

OM

(no

grou

pdi

ffer

ence

s)–

Wor

kst

atus

(Y;e

xerc

ise

grou

p)

Ear

lyun

supe

rvis

edcR

OM

-exe

rcis

eL

4

Gen

nis

etal

.,19

96R

est,

anal

gesi

cs,

Col

lar

for

2w

eeks

vs.

No

colla

rA

t6to

10w

eeks

:B

oth

grou

psim

prov

ed

–Pa

in(n

ogr

oup

diff

eren

ces)

No

reco

mm

enda

tion

onw

hich

trea

tmen

tto

choo

seL

5


Tabl

e3,

cont

inue

d

Stud

yIn

terv

entio

nsst

udie

dR

esul

tson

heal

thou

tcom

e(s)

GD

Cre

com

men

dsQ

ualit

yra

ting∗

McK

inne

yet

al.,

1989

;M

cKin

ney,

1989

Col

lar,

then

:R

est,

anal

gesi

csvs

.M

anip

ulat

ive

phys

ioth

erap

yvs

.Adv

ice,

exer

cise

At1

and

2m

onth

s:

–N

eck

mov

emen

t(Y

;phy

siot

hera

py;

exer

cise

)–

Pain

(Y;p

hysi

othe

rapy

;ex

erci

se)

Aft

er2

year

s:

–R

ecov

ery

(Y;A

dvic

e,ex

erci

segr

oup

only

)

Con

side

rm

anip

ulat

ive

phys

ioth

erap

yor

advi

ce,u

nsup

ervi

sed

exer

cise

whi

chev

erw

illle

aste

xace

rbat

ech

roni

city

fact

ors

L4

Mea

lyet

al.,

1986

Col

lar,

then

grad

ualm

obili

zatio

nvs

.Ac-

tive

trea

tmen

t:M

aitla

ndm

obili

zatio

n,un

supe

rvis

edcR

OM

exer

cise

At4

and

8w

eeks

:

–Pa

in(Y

;act

ive

trea

tmen

t)–

cRO

M(Y

;act

ive

trea

tmen

t)

Ear

lym

obili

zatio

n-ba

sed

trea

tmen

t(M

aitla

nd,u

nsup

ervi

sed

exer

cise

)L

4

Hen

drik

set

al.,

1996

Mul

timod

altr

eatm

ent

(sup

ervi

sed,

and

unsu

perv

ised

cRO

Mex

erci

seth

er-

mot

hera

py,

info

rmat

ion)

plus

ultr

a-re

izel

ectr

othe

rapy

vs.

Abo

vem

ul-

timod

altr

eatm

ent

with

out

ultr

a-re

izel

ectr

othe

rapy

At1

5m

inpo

st-t

reat

men

tan

d6

wee

ks:

–Pa

in(Y

;mul

timod

e,el

ectr

othe

rapy

)–

cRO

M(m

ixed

findi

ngs)

Shor

tco

urse

ofm

ultim

odal

trea

tmen

tw

ithul

tra-

reiz

elec

trot

hera

pyfo

rpa

inL

5

Ost

erba

uer

etal

.,19

92M

ostly

activ

ator

-ass

iste

dm

anip

ulat

ion,

optio

nal

inte

rfer

entia

lcu

rren

tA

t6w

eeks

and

1yea

r:

–Pa

in(Y

)–

cRO

M(Y

)

Act

ivat

or-a

ssis

ted

man

ipul

atio

nan

din

-te

rfer

entia

lcu

rren

tL

4

Penn

ieet

al.,

1990

Act

ive

trea

tmen

t:In

itial

colla

r,in

form

a-tio

n,tr

actio

n,un

supe

rvis

edex

erci

sevs

.In

itial

colla

r,co

llar

for

2w

eeks

and

rest

follo

wed

byun

supe

rvis

edex

erci

se

At6

,8w

eeks

and

5m

onth

:

–Pa

in(n

ogr

oup

diff

eren

ce)

–C

RO

M(n

ogr

oup

diff

eren

ces)

–W

ork

stat

us(n

ogr

oup

diff

eren

ces)

No

reco

mm

enda

tion

for

orag

ains

tstu

dyin

terv

entio

nsL

5

Ros

enfe

ldet

al.,

2003

Act

ive

trea

tmen

t:U

nsup

ervi

sed

and

su-

perv

ised

cRO

M-e

xerc

ise,

info

rmat

ion,

McK

enzi

em

obili

zatio

nvs

.U

nsup

er-

vise

dcR

OM

-exe

rcis

e,in

form

atio

n,re

st,

inst

ruct

ion

At6

mon

ths

and

3ye

ars:

–Pa

in(Y

;act

ive

trea

tmen

t)–

cRO

M(n

ogr

oup

diff

eren

ces)

–Si

ckle

ave

(Y;a

ctiv

etr

eatm

ent)

Uns

uper

vise

dan

dsu

perv

ised

cRO

Mex

-er

cise

,in

form

atio

nan

dM

cKen

zie

mo-

biliz

atio

nfo

rpa

in

L5

1◦Pr

imar

you

tcom

em

easu

re.

2◦Se

cond

ary

outc

ome

mea

sure

(s).

∗ As

asse

ssed

bylit

erat

ure

extr

acto

rsan

dre

view

edby

GD

C.T

hequ

ality

ratin

gof

the

evid

ence

onhe

alth

outc

omes

for

each

stud

yut

ilize

dth

eG

DC

adap

ted

OC

EB

Msc

ale

(Tab

le2)

.Y

:Yes

sign

ifica

ntim

prov

emen

trep

orte

dfo

rou

tcom

e.N

ogr

oup

diff

eren

ces

or“N

”:N

ost

atis

tical

lysi

gnifi

cant

diff

eren

ces

repo

rted

acro

sstr

eatm

ent

grou

ps.

nAD

Ls:

norm

alac

tiviti

esof

daily

livin

g.cR

OM

:cer

vica

lra

nge

ofm

otio

n.C

BT

:cog

nitiv

ebe

havi

oura

lth

erap

y.

L. Shaw et al. / A systematic review of chiropractic management of adults with whiplash-associated disorders 379Ta

ble

4

Lite

ratu

resu

mm

ary

and

qual

ityra

tings

ofth

eev

iden

cefo

rin

terv

entio

nsfo

rsu

bacu

tew

hipl

ash

Stud

yIn

terv

entio

nsst

udie

dO

utco

mes

GD

Cre

com

men

dsQ

ualit

yra

ting∗

Prov

inci

ali

etal

.,19

96M

ultim

odal

trea

tmen

t(ce

rvic

alm

assa

geor

mob

iliza

tion,

rela

xatio

n,po

stur

ein

-st

ruct

ion,

eye

fixat

ion

exer

cise

s,an

dps

ycho

logi

cal

supp

ort)

vs.E

lect

roth

era-

py,s

onic

mod

aliti

es

At6

mon

ths:

–cR

OM

(no

grou

pdi

ffer

ence

s)–

Pain

(Y;m

ultim

odal

trea

tmen

t)–

Self

-rat

ing

scal

e(Y

;mul

timod

altr

eatm

ent)

–W

ork

stat

us(Y

;mul

timod

altr

eatm

ent)

Use

shor

tcou

rse

ofm

ultim

odal

trea

tmen

tL

4

Scho

lten-

Pete

rset

al.,

2006

GP

care

:(e

duca

tion,

advi

cepr

omot

-in

gnA

DL

and

colla

rav

oida

nce,

grad

-ed

activ

ity,

co-i

nter

vent

ions

perm

itted

)vs

.Ph

ysio

ther

apy:

(edu

catio

n,ad

vice

,gr

aded

activ

ity,

supe

rvis

edex

erci

se,

man

ualt

hera

py)

At1

2an

d52

wee

ks:

1◦ou

tcom

es:

–N

eck

pain

inte

nsity

(no

grou

pdi

ffer

ence

s)–

Hea

dach

ein

tens

ity(n

ogr

oup

diff

eren

ces)

–W

ork

stat

us(Y

;at5

2w

eeks

for

GP

care

)

2◦ou

tcom

es:

–Fu

nctio

nal

reco

very

(Y;a

t52

wee

ksG

Pca

re)

–cR

OM

(Y;a

t12

wee

ksph

ysio

ther

apy)

–K

ines

ioph

obia

(no

grou

pdi

ffer

ence

s)–

Cop

ing

(Y;a

t52

wee

ksG

Pca

re)

–G

ener

alhe

alth

(no

grou

pdi

ffer

ence

s)–

SF-3

6su

bsca

les

(Y;a

t52

wee

ksG

Pca

re)

Add

supe

rvis

edex

erci

sean

dm

anua

lth

erap

yin

the

long

term

only

ifcR

OM

outc

omes

are

apr

iori

ty.

L5

Sode

rlun

det

al.,

2000

Uns

uper

vise

dcR

OM

-exe

rcis

e,po

stur

ean

dco

llara

void

ance

inst

ruct

ion

with

un-

supe

rvis

edki

naes

thet

icex

erci

sevs

.Un-

supe

rvis

edcR

OM

-exe

rcis

e,po

stur

ean

dco

llar

avoi

danc

ein

stru

ctio

nw

ithou

tki

-na

esth

etic

exer

cise

At3

and

6m

onth

s:B

oth

grou

psim

prov

ed

–Pa

inD

isab

ility

Inde

x(n

ogr

oup

diff

eren

ces)

–Pa

inIn

tens

ity(n

ogr

oup

diff

eren

ces)

–Se

lfE

ffica

cy(n

ogr

oup

diff

eren

ces)

–C

opin

g–

abili

tyto

decr

ease

pain

(Y;a

t6m

onth

ski

naes

thet

icgr

oup)

–cR

OM

(no

grou

pdi

ffer

ence

s)–

Kin

aest

hetic

abili

ty(n

ogr

oup

diff

eren

ces)

–Po

stur

e(n

ogr

oup

diff

eren

ces)

Uns

uper

vise

dcR

OM

exer

cise

and

pos-

ture

and

colla

rav

oida

nce

inst

ruct

ion

L4


Tabl

e4,

cont

inue

d

Stud

yIn

terv

entio

nsst

udie

dO

utco

mes

GD

Cre

com

men

dsQ

ualit

yra

ting∗

Bun

keto

rpet

al.,

2006

Supe

rvis

edex

erci

se,

unsu

perv

ised

low

-in

tens

ityae

robi

cex

erci

se,

com

preh

en-

sive

CB

Tvs

.Uns

uper

vise

dex

erci

se,u

n-su

perv

ised

low

-int

ensi

tyae

robi

cex

er-

cise

,com

preh

ensi

veC

BT

At3

and

9m

onth

s:1◦

outc

omes

:

–Se

lf-e

ffica

cy(Y

;at3

mon

ths

Supe

rvis

ed)

–K

ines

ioph

obia

(Y;a

t3m

onth

sSu

perv

ised

)–

Pain

Dis

abili

tyin

dex

(Y;a

t3m

onth

sSu

perv

ised

)

2◦ou

tcom

es:

–Pa

inin

tens

ity(n

ogr

oup

diff

eren

ces)

–Se

nsor

yan

daf

fect

ive

dim

ensi

ons

(no

grou

pdi

ffer

ence

s)–

Tend

erne

ss(n

ogr

oup

diff

eren

ces)

–C

RO

M(n

ogr

oup

diff

eren

ces)

–St

reng

th(n

ogr

oup

diff

eren

ces)

–A

bsen

teei

sm(n

ogr

oup

diff

eren

ces)

Supe

rvis

edex

erci

seL

5Pr

imar

you

tcom

esL

4Se

cond

ary

Out

com

es

Fial

kaet

al.,

1989

Ele

ctro

ther

apy

(int

erfe

rent

ial

curr

ent)

vs.N

otr

eatm

ent

At1

mon

th:

–Pa

in(n

ogr

oup

diff

eren

ces)

–H

eada

che

(Y;u

ntre

ated

)

Ifde

emed

nece

ssar

y,el

ectr

othe

rapy

for

pain

only

.L

4

1◦Pr

imar

you

tcom

em

easu

re.

2◦Se

cond

ary

outc

ome

mea

sure

(s).

∗ As

asse

ssed

bylit

erat

ure

extr

acto

rsan

dre

view

edby

GD

C.T

hequ

ality

ratin

gof

the

evid

ence

onhe

alth

outc

omes

for

each

stud

yut

ilize

dth

eG

DC

adap

ted

OC

EB

Msc

ale

(Tab

le2)

.Y

:Yes

sign

ifica

ntim

prov

emen

trep

orte

dfo

rou

tcom

e.N

ogr

oup

diff

eren

ces

or“N

”:N

ost

atis

tical

lysi

gnifi

cant

diff

eren

ces

repo

rted

acro

sstr

eatm

ent

grou

ps.

nAD

Ls:

norm

alac

tiviti

esof

daily

livin

g.cR

OM

:cer

vica

lra

nge

ofm

otio

n.C

BT

:cog

nitiv

ebe

havi

oura

lth

erap

y.


Tabl

e5

Lite

ratu

resu

mm

ary

and

qual

ityra

tings

ofth

eev

iden

cefo

rin

terv

entio

nsfo

rch

roni

cw

hipl

ash

Stud

yIn

terv

entio

nsst

udie

dO

utco

mes

GD

Cre

com

men

dsQ

ualit

yra

ting∗

Stew

art

etal

.,20

07In

stru

ctio

n/ad

vice

plus

exer

cise

vs.

In-

stru

ctio

n/ad

vice

alon

eN

ote:

Som

esu

bjec

tsso

ught

addi

tiona

ltr

eatm

ents

outs

ide

ofst

udy

At6

wee

ksan

d12

mon

ths:

1◦ou

tcom

es:

–Pa

inin

tens

ity(Y

;at6

wee

ks,e

xerc

ise)

–Pa

inbo

ther

som

enes

s(Y

;at6

wee

ks,e

xerc

ise)

–Fu

nctio

n(Y

;at6

wee

ks,e

xerc

ise)

2◦ou

tcom

es:

–D

isab

ility

(Y;a

t6w

eeks

–Q

oL(Y

;at6

wee

ks)

–G

loba

lper

ceiv

edef

fect

(Y;a

t6w

eeks

,exe

rcis

e)–

Wor

kst

atus

(no

grou

pdi

ffer

ence

s)

Rec

omm

ends

agai

nst

inst

ruct

ion/

advi

ceal

one

L5

Ster

ner

etal

.,20

01M

ultim

odal

reha

bilit

atio

npr

ogra

m(s

u-pe

rvis

edcR

OM

-exe

rcis

e,co

mpr

ehen

-si

vepa

inin

stru

ctio

n)N

ote:

Unc

ontr

olle

dpr

e-an

dpo

st-

trea

tmen

tde

sign

Imm

edia

tely

afte

rpr

ogra

man

dat

6m

onth

s:

–N

eck

pain

inte

nsity

(Y)

–U

pper

back

pain

inte

nsity

(Y;a

t6m

onth

s)–

Pain

othe

rre

gion

s(N

)–

Bec

kde

pres

sion

inde

x(N

)–

Pain

inve

ntor

y(N

)–

Cop

ing

(N)

–L

ife

satis

fact

ion

(N)

Rec

omm

ends

agai

nst

am

ediu

mco

urse

ofsu

perv

ised

cRO

M-e

xerc

ise

and

pain

inst

ruct

ion

for

pain

and

othe

rob

ject

ive

outc

omes

.

L4

Hei

kkila

etal

.,19

98U

nsup

ervi

sed

exer

cise

,co

mpr

ehen

sive

CB

TN

ote:

Unc

ontr

olle

dpr

e-an

dpo

st-

trea

tmen

tde

sign

Imm

edia

tely

afte

rpr

ogra

man

dat

2–3

year

s:

–C

opin

g(Y

)–

Lif

esa

tisfa

ctio

n(Y

)–

Abs

ente

eism

(Y;i

ncre

ased

)

Exe

rcis

ew

ithC

BT

com

pone

nts

L4

Ven

drig

etal

.,20

00Su

perv

ised

and

unsu

perv

ised

exer

cise

,C

BT

com

pone

ntN

ote:

Unc

ontr

olle

dpr

e-an

dpo

st-

trea

tmen

tde

sign

Imm

edia

tely

afte

rpr

ogra

man

dat

6m

onth

s:

–Pa

in(Y

)–

Self

-rep

orte

ddi

sabi

lity

(Y)

–So

mat

icco

mpl

aint

s(Y

)–

Las

situ

de(Y

)–

Dep

ress

ion

(Y)

–M

enta

ldul

lnes

s(Y

)–

Cog

nitiv

eco

mpl

aint

s(Y

)

Inst

ruct

ion

and

exer

cise

with

CB

Tco

mpo

nent

sL

4


Tabl

e5,

cont

inue

d

Stud

yIn

terv

entio

nsst

udie

dO

utco

mes

GD

Cre

com

men

dsQ

ualit

yra

ting∗

Fitz

-Rits

on,1

995

Uns

uper

vise

d4-

leve

lex

erci

se,

chir

o-pr

actic

care

vs.u

nsup

ervi

sed

phas

icex

-er

cise

s,ch

irop

ract

icca

re

At8

wee

ks:

–D

isab

ility

(Y)

Add

unsu

perv

ised

phas

icex

erci

seto

trea

tmen

tre

gim

ento

impr

ove

cerv

ical

disa

bilit

y

L4

Sode

rlun

det

al.,

2001

Uns

uper

vise

dcR

OM

-an

dst

abili

zing

-st

reng

th-e

xerc

ise,

info

rmat

ion,

rela

x-at

ion,

TE

NS,

acup

unct

ure,

heat

plus

CB

Tco

mpo

nent

svs

.A

bove

mod

aliti

esw

ithno

CB

Tco

mpo

nent

s

Imm

edia

tely

afte

rpr

ogra

man

dat

3m

onth

s:

–D

isab

ility

(no

grou

pdi

ffer

ence

s)–

Pain

inte

nsity

(no

grou

pdi

ffer

ence

s)–

cRO

M(n

ogr

oup

diff

eren

ces)

–Po

stur

e(n

ogr

oup

diff

eren

ces)

–G

loba

ltr

eatm

ent

effe

ct(Y

;CB

Tgr

oup)

Not

e:Su

bjec

tsw

ithhi

ghvs

.low

self

-effi

cacy

dem

onst

rate

dbe

tter

copi

ngou

tcom

es

Con

side

rCB

Tco

mpo

nent

sthr

ough

mul

-tid

isci

plin

ary

man

agem

ent

for

glob

alpa

in.

nAD

Ls,

and

com

plia

nce

with

ad-

vice

are

conc

erns

.

L4

Woo

dwar

det

al.,

1996

HV

LA

man

ipul

atio

n,pr

opri

ocep

tive

neur

omus

cula

rfa

cilit

atio

n,an

dcr

yoth

-er

apy.

Not

e:re

tros

pect

ive

case

anal

ysis

–Sy

mpt

omim

prov

emen

t(Y

)

Furt

her

rese

arch

onch

irop

ract

ictr

eat-

men

tsis

war

rant

ed.

L5

1◦Pr

imar

you

tcom

em

easu

re.

2◦Se

cond

ary

outc

ome

mea

sure

(s).

∗ As

asse

ssed

bylit

erat

ure

extr

acto

rsan

dre

view

edby

GD

C.T

hequ

ality

ratin

gof

the

evid

ence

onhe

alth

outc

omes

for

each

stud

yut

ilize

dth

eG

DC

adap

ted

OC

EB

Msc

ale

(Tab

le2)

.Y

:Yes

sign

ifica

ntim

prov

emen

tre

port

edfo

rou

tcom

e.N

ogr

oup

diff

eren

ces

or“N

”:N

ost

atis

tical

lysi

gnifi

cant

diff

eren

ces

repo

rted

acro

sstr

eatm

ent

grou

ps.

nAD

Ls:

norm

alac

tiviti

esof

daily

livin

g.cR

OM

:cer

vica

lra

nge

ofm

otio

n.C

BT

:cog

nitiv

ebe

havi

oura

lth

erap

y.


used less frequently were coping resources, life sat-isfaction, absenteeism, disability, somatic complaints,lassitude, depression, mental dullness, cognitive com-plaint, headache, self-efficacy, posture kinesthetic sen-sibility, kinesiophobia, strength and tenderness. In thisreview, no controlled studies were found in the pub-lished literature assessing HVLA manipulation for thetreatment of WAD in adults.

4.2. Review of the evidence

Fifteen studies are in acute WAD [5,6,16,18,22,29,36,42–44,50–52,56,59], 0–7 days since injury (Ta-ble 3). Note two papers by McKinney [42,43] cov-er one study in acute WAD and are therefore count-ed only once. Five studies are in subacute WAD [10,19,53,61,66], 1 week to 3 months since injury (Table4). Seven studies are in chronic WAD [20,28,65,70,71,75,77], defined as persistent pain and symptoms morethat 3 months since injury (Table 5). The review ofthe evidence is organized below by acute, subacute andchronic (WAD) categories. Each category begins witha summary of the best evidence where evidence acrossstudies consistently converged on the same health out-comes and recommendations for practice are provided.

Low quality evidence (4 controlled studies [5,16,42–44] satisfying best evidence synthesis criteria, McKin-ney studies count as one) suggests early mobilization,information/instruction, unsupervised and supervisedc-ROM exercise within multimodal treatment regimensimprove pain and cROM in acute WAD. Low qualityevidence (2 controlled studies [53,66] satisfying bestevidence synthesis criteria) suggests multimodal treat-ment: posture instruction, mobilization, massage andc-ROM exercise; improves pain in subacute WAD. Inchronic WAD, low quality evidence (2 controlled stud-ies and 3 cohort studies satisfying best evidence syn-thesis criteria) [20,28,65,70,75] suggests that unsuper-vised and supervised c-ROM-exercise and multidisci-plinary care (e.g. chiropractic plus psychological treat-ments such as CBT) support improved health outcomesincluding pain and related psychosocial symptoms.

In the original papers of this review, side effects ofvarious treatment modalities were not reported in detailby investigators. Consequently, risk profile(s) are notdiscussed in this review.

4.3. Treating clients with acute WAD

The literature provides sufficient evidence to es-tablish a baseline (two or more studies L4 or high-

er) to support chiropractic care of acute WAD. Evi-dence across treatment studies (Table 3) suggests a pat-tern that pain and cROM benefit from combinations ofthe following modalities: early mobilization, informa-tion/instruction, unsupervised and supervised cROM-exercise within multimodal treatment regimens [5,16,42–44].

Exercise protocols varied across published studies.In one prospective, randomized, controlled study of ac-tivity versus collar [5], clients enrolled within 3 daysof an accident. For the first week, treatment was de-livered with the client in a supine position: 3 sessionsof 10 min of ice applied to the neck muscles, and thenpassive mobilization of the neck through all tolerablecROM, followed by active mobilization, then super-vised strengthening and isometric exercises of the neckmuscles. In the second week, 2 sessions of the sameregimen were provided, but now in a seated position. Inthe third week, 2 sessions of unsupervised interscapu-lar muscle strengthening exercises were provided andinformation about maintaining normal neck posture.The study demonstrated that active therapy comparedto collar and rest resulted in significantly better rates ofrecovery.

McKinney et al. [42] studied 170 clients with un-defined WAD, randomized to 1 of 3 treatment groupswithin 72 hours of a whiplash injury. Prior to ran-domization, all clients received cervical spine radiol-ogy, cROM and pain assessments, soft cervical col-lar, and analgesia (1000 mg Co-dydramol QID). Treat-ment group 1 (rest and analgesia) included a one-timegeneral information session on self-mobilization aftera rest period of 10 to 14 days. Group 2 (active out-patient physiotherapy) included physiotherapy over 6weeks with three 40-minute sessions per week of in-dividualized therapy using the “full gamut” of knownmethods (totaling 10 hours: hot and cold applications,short-wave diathermy, hydrotherapy, traction, and ac-tive and passive repetitive movements [as per McKen-zie and Maitland]), and defined unsupervised cROM-exercises. Group 3 (mobilization advice) included one-time, 30-minute verbal and written (encouraging) in-struction about posture correction, muscle relaxation,unsupervised cROM-exercises that were also demon-strated, and the use of analgesia, heat and avoiding re-liance on collar use. Outpatient physiotherapy (Group2) exhibited similar outcomes on cervical pain andcROM at 1 and 2 months as Group 3 (mobilizationadvice). Both groups demonstrated significantly bet-ter outcomes on pain severity scores than initial restfollowed by self-mobilization (Group 1). In a 2-year


follow-up of the same clients [43], longer-term out-comes across the 3 treatment groups were compared.Unsupervised cROM-exercise (Group 3) demonstrat-ed the most favorable outcomes by 2 years. The per-centage of clients with persistent symptoms was 46%for rest and self-mobilization, 44% for normal hospitalphysiotherapy, 23% for unsupervised cROM-exercise(Group 3), and 41% among a group of subjects thatdropped out of the study. For the dropouts and allclients but the rest and self-mobilization group, the du-ration of collar wearing differentiated those having per-sistent symptoms at 2 years from those without symp-toms. This suggests that collar slowed recovery andspurred chronicity in some cases.

Mealy et al. [44] studied 61 clients with undefinedWAD randomized to one of two groups: (1) Collar:soft cervical collar and rest for 2 weeks followed bycollar and gradual mobilization, (2) Active Treatment:ice in the first 24 hours and then an unsupervisedcROM-exercise combination (neck mobilization [Mait-land technique] with heat applied after each treatment),daily unsupervised cROM-exercises within the limitsof pain every waking hour at home. All clients tookoral analgesics as needed. The Active Treatment groupshowed improved pain and movement at both 4 and8 weeks. The degree of improvement seen in the ActiveTreatment group compared with the Collar group wassignificantly greater for both cROM and pain intensity.

In an additional study assessing collar, Crawford etal. [16]. studied 108 clients with WAD-1 to -2 who re-ceived a “standard” soft cervical collar and nonsteroidalanti-inflammatory drugs (NSAIDs) at first presentation.Within a few days, clients were randomized to either asoft cervical collar (average use 26-days), or treatmentof unsupervised cROM-exercise with instructions tomobilize without the collar as soon as possible (averagecollar use was 6-days before mobilizing). At 3 weeks,the collar group was switched to the exercise treatment.No differences were found between groups for pain,range of motion, or activities of daily living at 3-, 12-and 52-week follow-up visits. The collar group tooksignificantly longer to return to work. Treatment withsoft collar had no obvious benefit in terms of functionalrecovery of WAD and was associated with a prolongedtime off work.

Evidence suggests that clients with acute WAD maybenefit from combinations of the following modali-ties: early mobilization, unsupervised and supervisedcROM-exercise, and instruction. Exercise protocolsvaried in the literature. For this reason, chiropractorsshould base prescribed exercise regimens on clinical

experience and a client’s specific situation. The GDCconsensus is that chiropractors should use a balanceof passive and active care in relation to each client’sclinical presentation and the treatment regime shouldbecome more active with time. Resumption of normalactivities of daily living should be encouraged. Evi-dence does not currently support the use of collar toimprove health outcomes.

4.4. Treating clients with subacute WAD

Two L4 studies provide corroborating evidence tosupport the use of multiple modalities [53,66] toachieve improved pain outcomes in subacute WAD (Ta-ble 4). Provinciali et al. [53] studied 60 clients withWAD-1 or WAD-2 an average of 30 days after in-jury. One treatment group received multimodal treat-ment (massage or mobilization, training for relaxation[diaphragmatic breathing in supine position] and pos-ture [based on “Neck school” principles], psycholog-ical support, and eye fixation exercises). The secondgroup received iontophoresis with calcium chloride andan electrotherapy treatment of transcutaneous electri-cal nerve stimulation (TENS), pulsed electromagneticfield therapy (PEMF, as per Foley-Nolan), and “fre-quent” ultrasound. Both groups exhibited improvementin cROM and pain. Compared with the electrotherapygroup, the multimodal group returned to work soon-er within the 6-month follow-up period, showed betterself-rated improvement at 15 days (the end of treat-ment) and 6 months, and reported less pain at 15 days,1 and 6 months. There were no differences betweengroups for cROM at 15 days, 1 or 6 months.

In an additional study, mobilization and prognosticfactors were studied in 59 clients with WAD-1 to -3on average 20 days after injury [66]. Prior to random-ization, all clients were instructed to resume normalactivities of daily living (nADL) as soon as possible.Analgesics were permitted. Two home exercise pro-grams were compared: one group was prescribed atleast 3-times daily unsupervised cROM-exercise thatincluded pacing activities and cROM to the limit ofpain, and was told to keep their neck from getting cold,and about posture and lifting. The second group re-ceived all of the first group’s interventions, as well as aprescription for 3-times daily unsupervised kinesthet-ic exercise. At 3 and 6 months, both groups showedsimilar improvements in disability, coping strategies,pain intensity, cervical posture, cROM, and cervicalkinesthetic sensibility.


Literature suggests that clients with subacute WADmay benefit from multiple modalities to improve pain:posture instruction, mobilization, massage and c-ROMexercise. When choosing two or more outcome equiv-alent treatments, choose the one that is least likely tocontribute to a client’s propensity for chronic WAD.The treatment that is less complex and less costly isrecommended if both treatments suggest similar impacton chronicity. Exercise protocols varied in the litera-ture. For this reason, chiropractors should base pre-scribed exercise regimens on clinical experience andon a client’s specific situation. GDC consensus is thatfuture investigations are needed to evaluate the effectof treatments in subacute WAD and that chiropractorsshould use a balance of passive and active care in rela-tion to each client’s clinical presentation and the treat-ment regime should become increasingly more activewith time.

4.5. Treating clients with chronic WAD

Studies in the chronic category suggest that there arebenefits across a range of health outcomes [20,28,65,70,75]. For instance, health outcomes examined in-clude pain, disability, cROM, posture, coping resourcesand life satisfaction.

Fitz-Ritson [20] evaluated whether “phasic” exercis-es benefit chronic whiplash clients. In a randomizedcontrolled study, one group of subjects (n = 15) wasprescribed standard unsupervised exercises (stretch-ing/isometric/isokinetic) and chiropractic therapy. Ina second group (n = 15), subjects completed phasicexercises consisting of rapid eye-head-neck-armmove-ments and chiropractic therapy. Both groups exercisedfor a minimum of 4 times per week for 8 weeks. At theend of treatment, both groups showed improved neckdisability index scores, with the unsupervised phasicexercise group showing greater improvement.

Heikkila et al. [28] studied the effects of multidis-ciplinary rehabilitation over 6 weeks with 40 chron-ic whiplash clients. Treatment included various unsu-pervised exercises and counseling using cognitive be-havioral therapy methods. Approximately half of theclients experienced improved coping and life satisfac-tion 2 years after treatment. One caveat, however, isthat clients also reported significantly more sick-leaveabsenteeism 1 and 2 years after treatment compared tobaseline.

Soderlund and Lindberg [65] studied 33 clients withchronic WAD-1 to -3. Clients were randomized to 2groups that each received a maximum of 12 treatments

over an undefined period. In addition to usual phys-iotherapy care, the experimental group received en-durance and coordination cROM-exercises, and a medi-an of 11 treatments utilizing cognitive behavioral ther-apy (CBT) principles. CBT treatment first included“functional behavioral analysis” that identified problembehaviors and treatment goals, information about skillsof self-efficacy and coping with pain, training about re-laxation, and “re-education” about posture. CBT alsoaddressed the integration of acquired skills into nADL.Post-treatment and at 3 months, there was no differencebetween groups in pain intensity, disability, cROM, orcervical-spine coordination. Using subjective globalquestions, the CBT group reported significantly lesspain than the control group immediately after treat-ment and 3 months later. At 3 months after treatment,the CBT group also reported greater ability to performnADL and greater compliance with taught strategies.

Sterner et al. [70] studied 88 WAD-1 to -3 clientswith symptoms lasting 3 months to 1 year, and wereallocated to receive treatment three times weekly (over5 weeks) or twice-weekly (over 6 weeks). The treat-ment included group meetings at the client’s workplace,ergonomics, body awareness therapy, relaxation, phys-ical activity including hydrotherapy, and instructionabout pain, pharmacology, stress, and the psychologi-cal consequences of pain. Supervised cROM-exercisesfacilitating neck activity and normal movement pat-terns were included in the ergonomic, physical activi-ty and body awareness components. Clients reportedsatisfaction with the therapy regimen 6 months aftertreatment with diminished neck and upper back pain.No differences were found, however, for functional orpsychological outcomes.

Vendrig et al. [75] assessed 26 WAD-1 to -2 clientswith symptoms lasting at least 6 months, who re-ceived 4 weeks of a daily multimodal treatment focusedon behavior modification. Treatment addressed pain-eliciting behavior, reduced collar use, and included ex-ercise, assistance returning to work, and explorationof subjects’ beliefs regarding symptoms and disability.Pharmacotherapy was permitted; 42% of clients usedanalgesics at 6 months. Improvements in pain intensi-ty, disability, and the Minnesota Multi-phasic Person-ality Inventory (MMPI) scales for somatic complaints,lassitude, depression, mental dullness, and cognitivecomplaints were seen at the end of treatment and at6 months follow-up.

Best evidence synthesis across these studies in thechronic category demonstrates improved health out-comes for pain and/or disability depending upon a


The WAD-Plus Model

Fig. 1. The WAD-Plus model takes into consideration (1) WAD grade (2) time since injury (3) pain experience and (4) chronicity factors.

combination of unsupervised exercise [20,28], super-vised exercise [65,75] and cognitive behavioral ther-apy (CBT) [28,65,75] (Table 5). Overall, the treat-ment modalities in the management of chronic WADare more likely to improve health outcomes if the clientis actively involved in care and if the modalities areinteractive, that is they are characterized by active in-volvement and responsibilities of both the client andthe practitioner, and if they are multidisciplinary.

Evidence suggests that clients with chronic WADcan benefit from combinations of the following modal-ities: unsupervised and supervised cROM-exercise andpsychological counseling, such as CBT. The GDC con-sensus suggests that multidisciplinary care (e.g., chiro-practic plus CBT) supports improved health outcomes.The GDC consensus is to balance passive and activecare in relation to each client’s clinical presentation.

4.6. Advancing the management of WAD through TheWAD-Plus Model

The evidence review revealed methodological het-erogeneity, diversity in the treatment approaches andknowledge gaps for the management of WAD. Thebaseline of evidence for chiropractic treatments ofWAD is for the most part low or based on expert con-

sensus. This paper supports findings of other reviewsin that active treatments over passive produce betterresults [31,76]. Similarly, the evidence in other re-views suggests that cervical stretching and strength-ening exercises may be effective for the treatment ofacute and possibly chronic whiplash [36,58]. However,there is limited evidence of benefit for electrotherapiesin WAD [37].

Gaps in this review include the lack of studies onHVLA, the absence of reporting of adverse events instudies, a lack of consistency in the reporting on studysubjects, WAD grades, health outcomes, time sinceinjury, lack of common terms and definitions for a short,medium or long course of treatment and the healthoutcomes across time. These inconsistencies suggestthat there is a need for a framework that amalgamatesfour dimensions of care important for the managementof WAD: knowledge of WAD grade, time since injury,pain experience and chronicity. Thus, the GDC positsthat the WAD-Plus Model (Fig. 1) be used to improveconsistency in clinical management of WAD and in turnbe used in future intervention studies of WAD.

The WAD-Plus Model refers to the assessment ofWAD grade and 3 other important dimensions rele-vant to client care: time since injury, pain experienceand chronicity factors (Fig. 1). As a model, it offers


WAD Grades Range from WAD-1 to WAD-4

Fig. 2. Adapted from the work of The Quebec Task Force [11] and BJD TF [27] WAD grades range from WAD-1 to WAD-4 with all symptomsdirectly related to whiplash injury. The least serious, WAD-1 encompasses symptoms of neck stiffness or pain. WAD-2 includes symptomsof neck pain, stiffness or tenderness, with musculoskeletal signs (point tenderness, decreased cROM and symptoms substantially interfere withnADL). WAD-3 includes neck pain, decreased or absent deep tendon reflexes, weakness, sensory deficits or other neurological signs. WAD-4 isdetermined to be the most serious and when clients seek care in the acute or subacute phase of injury with unhealed fractures, unstable healedfractures or increasing neurological symptoms, immediate referral to the appropriate professional is necessary. Clients with chronic WAD-4 withstable healed fractures and without neurological signs can be assessed for chiropractic treatment.

a multipurpose structure: 1) to guide the mapping ofevidence-based and expert consensus information con-sistent with the clinical assessment process; 2) to pro-vide a conceptual model to support the future develop-ment of relevant treatment algorithms illustrating thepractice dimensions used in WAD interventions; and3) to provide a basis for future research studies. Therelevant literature from the review supporting the de-velopment of the WAD-Plus Model and its dimensionsare elaborated. In this section, GDC recommendationsfor chiropractic practice consistent with the dimensionsin the WAD-Plus Model are put forward. While theserecommendations for the use of WAD-Plus Model arespecific to chiropractic management, other disciplinesare encouraged to use these dimensions to support in-terdisciplinary approaches to the care and managementof WAD. The GDC recommends that all four dimen-sions of the WAD-Plus Model should be considered aspart of WAD care.

4.6.1. WAD GradeWhiplash injury and the resulting signs and symp-

toms of WAD are delineated by WAD grades 1 through

4 (Fig. 2). The following definitions are an evolutionfrom the current literature and documents that haveshaped WAD grades [26,68]. A client’s exposure tothe intensity of a whiplash-provoking accident is re-flected in the resulting WAD grade with a higher graderepresenting greater symptom burden. The least se-rious, WAD-1, encompasses symptoms of neck stiff-ness or pain with no or minor interference with nADL.WAD-2 includes symptoms of neck pain, stiffness ortenderness; musculoskeletal signs (decreased cROMand point tenderness); and the symptoms substantiallyinterfere with nADL. Most clients with WAD presentwith WAD-2 [68]. WAD-3 includes neck pain, de-creased or absent deep tendon reflexes, weakness, sen-sory deficits or other neurological signs. WAD-4 isdetermined to be the most serious and when clientsseek care in the acute or subacute phase of injury withunhealed fractures, dislocations, unstable healed frac-tures or increasing neurological symptoms, immediatereferral to the appropriate professionals is necessary.Clients with chronic WAD-4 with stable healed frac-tures and without neurological signs can be assessed forchiropractic treatment. WAD-0 has neither symptoms


C-spine imaging is recommended for patients with trauma unless they meet all of the following criteria:

Absence of posterior midline cervical-spine tendernessPatients with midline posterior bony cervical-spine tenderness present with reports of pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra, or if the patient expresses pain with direct palpation of any cervical spinous process.

No evidence of intoxicationPatients should be considered intoxicated if they have a recent history provided by the patient or an observer of intoxicating ingestion or evidence of intoxication on physical exam such as an odor of alcohol, slurred speech, ataxia, or any behavior indicative of intoxication. Patients may also be considered to be intoxicated if laboratory tests are positive for alcohol or drugs that affect the level of alertness.

A normal level of alertness and consciousness (baseline mental status)Patients with an altered level of alertness may include any of the following: a Glasgow Coma Scale score of 14 or less; disorientation to person, place, time, or events; inability to recall three objects at five minutes; a delayed or inappropriateresponse to external stimuli; or alternative findings consistentwith altered mental status.

Absence of focal neurological deficitPatients with a focal neurological deficit is any focal neurological finding on motor or sensory examination.

Absence of any distracting injuriesPatients with a distracting injury is any condition that, in theexaminer s judgment could be producing enough pain so as to distract the patient from another, particularly cervical, injury. Such injuries may include a long-bone fracture; a visceral injury; a significant laceration, degloving injury, or crush injury; large burns; or any other injury causing acute functional impairment.

The Canadian Cervical-Spine Rule The NEXUS Low Risk CriteriaTo be used on alert (Glasgow Coma Scale score=15) and stable trauma patients where cervical spine (C-spine) injury is a concern

Is there a high-risk factor necessitatingradiography?Age > _ 65 years or a significant mechanism of injury or paresthesias in the extremities

Is there any low-risk factor permitting safeassessment of range of motion?Was it a simple rear-end collision (excludingrollover, collision with bus, large truck, or vehicletraveling at high speeds, or being pushed intooncoming traffic)?Was the patient found seated in the EmergencyDepartment or ambulatory after the incident?Was there delayed onset of neck pain or absenceof any midline cervical-spine tenderness.

Able to rotate neck actively?45 degrees right and left

No

Yes

No Radiography

Yes

Radiography

Yes

No

Unable

*Adapted with permission from Stiell et al. [72]

Fig. 3.

nor requirement for treatment and is therefore excludedfrom the model.

The GDC consensus is that chiropractors conducta focused examination to establish each client’s WADgrade prior to treatment and during reevaluation. Chi-ropractors may use the Canadian Cervical Spine (C-Spine) Rule or the NEXUS low-risk criteria to screenlow risk injuries and to rule out the need for furtherimaging of neck trauma in adult patients [72,73]. SeeFig. 3. The chiropractor should consider if the currentpresentation of WAD is a resolving disorder of a moresevere grade. At each reassessment, the chiropractorshould consider if a reclassification to a greater WADgrade may result from the evolving nature of WAD orfrom a delayed onset of signs or symptoms.

4.6.2. Time since injuryTissue is differently susceptible to interventions over

time, and care must be tailored accordingly. Three

well-accepted stages of soft tissue healing are in-flammation, repair and remodeling [38]. Acute, in-flamed soft tissue is swollen, erythematous and touch-sensitive. In a healthy person, injured tissue demon-strates an acute inflammatory response for several days.During this time, the client experiences increased bloodflow as repair elements are delivered to the affected tis-sue and cellular debris is removed from it. Soft tissuethen enters repair and remodeling phases lasting fromweeks to months [38]. Each client heals at a differentrate and tissue healing may be slower in a WAD clientwho is otherwise ill. An ill client who shows inflamedsoft tissue for months should be treated with an acuteclinical approach for that period. As a result, while timesince injury is used to designate phases when tissue isdifferently susceptible to interventions, chiropractorsare responsible for ensuring that a client is truly in aparticular phase of healing. The GDC consensus isthat the chiropractor should identify each client’s phase


of healing prior to treatment (e.g. acute, subacute, orchronic). The phase can be established using the vari-able of time since injury and then adjusted to a client’sclinical situation.

4.6.3. Pain experienceWhiplash-associated pain in the acute phase, when

tissue damage is most severe and unresolved, is relat-ed foremost to the objective severity of injury. In thisphase, pain is directly the result of sensory signalingof tissue damage. A client’s pain at any time may al-so include psychosocial features of the injury and painexperience [46]. Psychosocial features of pain resultfrom a client’s perceptions about the importance andmeaning of sensory pain. The consequences of psy-chosocial pain range from worse described pain (e.g.,more intense, more widespread) through to lifestylechanges (e.g., poor participation in nADL, functionaldisability), physical effects (e.g., panic) and psycho-logical effects (e.g., poor ego-integrity, poor environ-ment mastery). Consequences can involve feelings ofuncertainty, anxiety, distress, hopelessness, helpless-ness and fear of pain or pain-causing possibilities. Painmay be influenced by gender, a client’s belief in the ef-fectiveness of treatment, strong emotional states (e.g.,anxiety) and cultural, family and work factors [22,34,39,46,54]. The most overt is emotionality: a reactionto pain-related situations, ideas, interventions or con-sequences that is judged by expert opinion to be exces-sive and self-harming. Management of psychosocialfeatures within a client’s pain experience is ubiquitouswithin chiropractic care. Practice should involve anassessment of the proportion of psychosocial featureswithin a client’s pain experience. Psychosocial painhas been studied in WAD. Soderlund et al. [66] con-cluded that among 33 WAD-1 to WAD-3 subjects withcontinuous symptoms 3 months after injury, subjectswith high Self-Efficacy Scale [62] scores were betterable to manage their pain (e.g. greater confidence intheir ability to complete activities of daily living). Aseparate WAD study with 40 subjects [10] showed lowself-efficacy is predictive of persistent disability. Con-sequently, determining the proportion of psychosocialpain within a client’s experience is clinically meaning-ful. If clinical judgment suggests that a client has a highproportion of psychosocial pain, consider performinga validated test to confirm the assessment. The GDCdeemed that at least several tools are helpful in measur-ing psychosocial pain within a client’s pain experienceand inform the decision as to the need for multidisci-plinary care. These include the Bournemouth Ques-

tionnaire [4], McGill Pain Questionnaire [45], Self Ef-ficacy Scale [62] and Pain Catastrophizing Scale [74].If a client has a high proportion of psychosocial pain,focus on multidisciplinary management of cognitive orbehavioral components outside of chiropractic care.

4.6.4. Chronicity factorsThe likelihood of chronicity can be roughly predicted

by the presence or intensity of risk factors before or af-ter injury. One study identified initial cervical disabil-ity, high levels of psychological distress, the severityof signs and symptoms (WAD grade) and the collisionfactors as predictors of pain at 1, 3 and 12 months [3].Another study [30] showed that the use of pain medi-cation before the whiplash-causing accident predictedpoorer recovery in the long term. Separately, in exten-sively treated clients with undefined WAD, low painimmediately after injury was associated with “recov-ery” [42]. These observations support the conclusionof several studies that high initial pain is predictive ofpoor recovery [3,12,60]. Hendriks et al. [30] analyzed119 subjects with WAD-1 or WAD-2 two weeks afterinjury for factors predictive of functional recovery at 4,12 or 52 weeks. Results suggest that general recoveryin the medium and long term was predicted at 2 weeksby youthfulness, high level of education, low intensityof neck pain, lack of somatization or sleep difficulties,ableness in work activities, male gender, marital status,greater cROM and less than 9 complaints. Sterling etal. [69] measured disability for 76 clients with WAD-2or -3 within 1 month after injury. Subjects were treat-ed predominantly with physiotherapy, but some chi-ropractic, acupuncture and pharmacotherapy were al-so used. General recovery was predicted at 6 monthsby youthfulness, male gender, low Neck Disability In-dex scores, normal range of rotation, high cold painthresholds, good sympathetic reactivity and low emo-tional distress. A client’s chronicity factors can guidetreatment for each phase of healing.

The GDC recommends that chiropractors use thecriteria put forth by the BJD TF for the considerationand identification of potential chronicity factors [11]:

– Demographic and socioeconomic factors: In-creasing age in years, lower educational level, fe-male gender are associated with chronicity;

– Prior health or pain status: Prior cervical painor headache before injury predicts greater pain orpoorer recovery;

– Collision factors: Are inconsistently predictive ofpain or recovery;


– Symptom severity: Initial cervical disability andhigh pain immediately after injury predicts poorerrecovery;

– Psychological and social factors: Passive cop-ing predicts greater pain or poorer recovery; de-pression, kinesiophobia, catastrophizing and ini-tial post-injury anxiety predicts poorer recovery;Low self-efficacy predicts greater pain or poorerrecovery;

– Compensation and legal factors: Are predictiveof poorer recovery;

– Health behaviors and interventions: Frequentpost-injury use of health care is associated withpoorer recovery.

The GDC consensus is that the chiropractor shouldassess the client’s risk for chronicity in the acute phase,with a view to the client’s longer-term care. If required,the chiropractor should prepare the client for a differentpattern of care once tissue healing has advanced tothe repair/remodeling phase. The chiropractor shouldchoose treatment options that limit a client’s propensityfor chronicity and that are simple and cost-effective.

The WAD-Plus Model is relevant to clinical practiceand is presented by the GDC as an important tool forchiropractors, for researchers and clinicians support-ing multidisciplinary approaches in managing pain anddisability associated with WAD. This model addressesthe complexities of WAD and organizes care with re-spect to a client’s clinical context (WAD grade, timesince injury, pain experience, chronicity factors). As-sessment of each of the WAD-Plus dimensions helpsguide the frequency, dosage and duration of treatmentmodalities. In addition, the model helps flag when aclient is improving on one dimension but not another,and care can be tailored accordingly.

Organizing the evidence by acute, subacute, andchronic WAD is clinically relevant because response totreatment is different across each category. Treatmentmodalities applicable to and recommended for acuteor subacute WAD (e.g. posture advice/instruction) arenot necessarily appropriate for chronic WAD. Similar-ly, treatment modalities for chronic WAD are not nec-essarily applicable for acute WAD (e.g. psychologicalcounseling/CBT).

The dimensions in the WAD-Plus Model and thetrends in the evidence supporting multidimensional ap-proaches in managing chronic pain can be used as aframework for guiding interprofessional or multidisci-plinary approaches in WAD care. The WAD-Plus Mod-el provides a common basis for understanding the realmof factors that need to be considered in establishing

shared goals for care among professionals working withpersons with acute, subacute or chronic WAD. As well,the four dimensions of the WAD-Plus Model can sup-port multidisciplinary teams of professionals in choos-ing assessments that add essential knowledge aboutthese dimensions and to support the realm of inter-ventions needed to comprehensively address the com-plex issues associated with the prevention of chronicityand subsequent disability. For groups of researcherswith shared interests in improving the health and occu-pational outcomes of persons experiencing WAD, theWAD-Plus Model affords a common set of dimensionsto support comparison of interventions for acute, suba-cute and chronic WAD across studies.

5. Discussion

5.1. The need for further research

The findings of this review of the literature under-score that there is a baseline of low levels of evidenceto support the chiropractic management of WAD. Find-ings from this review also highlight that the evidenceis suggestive or determined by consensus rather thanconclusive evidence. In addition gaps and limitationsin the current research are identified. As a result, effortsare needed to improve the rigor and quality of studiesto advance the evidence base on effective chiropractictreatment of clients with WAD. Research strategies foraddressing gaps, enhancing future investigations andusing the dimensions of the WAD-Plus Model to sup-port a systematic approach to the study of chiropracticWAD care need to be developed. It is suggested thatthe WAD-Plus Model might enhance the comparisonof information collected and studies relevant to advanc-ing the evidence of chiropractic management of clientswith WAD. Furthermore, research is needed on the di-mensions of the WAD-Plus Model for use in multidis-ciplinary approaches to WAD management.

5.2. Gaps in current evidence on WAD interventions

This paper does not provide a comprehensive reviewof all chiropractic treatment modalities. If a treatmentis not mentioned, it is because the GDC did not retrievepublished evidence to comment about it based on pre-defined literature search criteria. In addition, there isresearch that utilizes claims data to assess the prognosisof whiplash clients that was not retrieved by the GDC’sliterature search because specific treatment modalities


and WAD grades were undefined in the original pa-pers [13]. Nevertheless, such findings are of interestto this review because results support the notion thatactivation improves prognosis in WAD. Also, clients’over reliance on clinical care within the first month fol-lowing whiplash injury may delay recovery possibly bypromoting passive coping strategies [13,14].

A major challenge with intervention studies on WADis a lack of consistency in: reporting on study subjects,WAD grades, health outcomes, time since injury, lackof common terms and definitions for a short, mediumor long course of treatment and the health outcomesacross time. The lack of a systematic or standard ap-proach to the study of WAD interventions in the acute,subacute or chronic stages in treating WAD will con-tinue to contribute to the complexity and difficulties inintegrating evidence relevant for practice. Findings inthis paper show that the majority of the studies reflectinterventions used in the acute phase and that there isless research on interventions in subacute and chron-ic WAD. More study is indicated across these phasesof WAD. In addition, while cROM and pain are com-monly reported health outcomes in the acute period,the health outcomes examined in subacute and chronicare diverse. Future study of health outcomes in chiro-practic care for WAD should be congruent and consis-tent. Studies should use health outcome measures thatare coherent with the intervention, the time period ofcare, and the clients’ goals for returning to work and/orresuming meaningful participation in daily and sociallife. Moreover, many of the intervention studies did notreport adequate control groups, nor did they explicitlyreport treatment effects over time. Thus, the lack ofcontrol groups makes it difficult to support conclusionsas to whether a specific treatment is more effective thanno treatment or alternative treatment. While this mayreflect the ethical difficulty associated with not treatingclients, there are study designs that will support thecomparison of treatments on health outcomes.

Most North American chiropractors use diversifiedtechnique that involves HVLA manipulation [15]. Yetin the literature searches completed, only 1 study usingretrospective case analyses investigated HVLA [77].No other studies were found that directly support orrefute the use of HVLA manipulation for the treatmentof WAD. More specific research on the use of HVLAmanipulation in the treatment of WAD is warranted.

5.3. Advancing research on WAD and healthoutcomes

Beyond the lack of studies on HVLA there is a needto address the other remaining gaps using methods that

provide a better understanding of WAD. Notably ab-sent in all studies was a discussion on adverse events inthe treatment of WAD. Future studies should addressthe risk of adverse events, even if none are found in theexisting study. In addition, WAD grade and phase ofhealing are fairly well understood, whereas chronicityfactors and psychosocial features of WAD are poorlyunderstood. It is for these reasons that the WAD-PlusModel was developed as a framework for understand-ing the clinical dimensions of WAD. An understandingof the evidence-based treatment of WAD will be limit-ed until all dimensions are systematically disclosed instudy subject descriptions and outcomes. Research isneeded in this area not only to support evidence-basedcare of WAD but also to address issues relevant to thecontext of chiropractic WAD care.

The GDC consensus is that there is a need for dis-cussion of adverse events in WAD research, even if noadverse events are encountered. There is also a need forresearch which must address and document the clients’pain experience (sensory vs. psychosocial), chronicityfactors, WAD grade and time since injury to ensure therigor of results and data interpretation. Furthermore,there is also a need for interdisciplinary research in-corporating the WAD-Plus Model. Research is neededon the use of the dimensions in this model in guid-ing clients and interprofessional teams of clinicians ingraduating the resumption of activities and occupationssuch as productive work.

Future WAD studies will require research designs us-ing active comparators, non-treatment and/or placebogroup(s) to enhance the evidence-base for client care.The lack of systematically reported studies presents apractical challenge for generating evidence-based treat-ment recommendations. While this situation resultsfrom the multidimensional nature of the disorder, theidiosyncratic way that the condition presents and limi-tations in research funding, more consistent and struc-tured effort is needed. The GDC consensus is thatthere needs to be studies on combinations of treatmentmodalities rather than individual modalities rarely usedalone or in ad-hoc combinations. Studies should bestructured (when possible) using systematic, validat-ed methods (e.g., Consolidated Standards of ReportingTrials [CONSORT], Transparent Reporting of Evalua-tions with Non-randomized Designs [TREND]) [1,17,47].

This review identified that WAD intervention studiesutilize a variable range of measures in evaluating the ef-fect of treatment on health outcomes. Pain and cROMare the most consistently used outcomes. The tools and


instruments used in determining those outcomes varywidely in reliability and validity. This inconsistencymakes it difficult to compare outcomes across studiesand to build knowledge. Serious efforts are needed toidentify rigorous outcome measures that are consistentand congruent with the proposed WAD-Plus Model andcan be used by all disciplines interested in systemat-ically advancing the evidence and knowledge on themanagement of WAD. The GDC recommends that aninterdisciplinary consensus be developed on a consis-tent standard of outcome measures to be used for allfuture studies on WAD.

In addition the outcome measures used in the studyon the care and management of WAD are focused onhealth outcomes of the person. While these outcomesare valued in terms of evidence-based practice by healthcare professionals, they are not the only outcomes ofconcern by persons with WAD. Persons experiencingWAD, live, function and work in a daily life context, yetlittle effort or attention is placed on the improved socialor occupational outcomes for persons with WAD. Giv-en, that the limited evidence that does exist suggestsmore active treatments and more involvement of per-sons in their care, more research is needed to identifyand measure the broader realm of health, participationand productivity outcomes that are achieved throughthe management of WAD.

6. Conclusion

There is a baseline of low levels of evidence thatsuggests chiropractic care improves cROM and painin the management of WAD. This knowledge base ofevidence can be strengthened on WAD care by effortsof researchers and clinicians across disciplines with ashared interest in WAD to adopt a more consistent ap-proach to studying WAD interventions and expandingthe realm of outcomes used. The WAD-Plus Modelis posited for use to improve consistency and quali-ty in chiropractic care, interprofessional approaches tothe management of WAD care, and advance researchneeded to inform evidence-based WAD practice.

Acknowledgements

This paper is dedicated to the memory of NormandDanis, DC, in light of his leadership and guidance asco-chair of the GDC between 2002 and 2007. Inputfrom the following individuals is gratefully acknowl-

edged on earlier versions of this work: Cam McDer-maid DC; Donald R Murphy DC, DACAN; RichardRoy DC MSc; Dave Anderson BSc, DC; Andrea FurlanPhD, MD; Steven Silk BSc, DC; Ron Brady DC; Gray-den Bridge DC; H James Duncan BFA, CAE; Wan-da Lee MacPhee BSc, DC; Keith Thomson BSc, DC,ND; Dean Wright DC; Peter Waite BA, CAE. Liter-ature search and evidence extraction teams included:Bart W Koes PhD; Gwendolijne GM Scholten-PeetersPT, MT, PhD; Arianne P Verhagen PT, MT, PhD; San-dra van Wijngaarden PT, MT, MSc; Thor EglingtonMSc, RN; Anne Taylor-Vaisey MLS, and ad hoc con-sultation with some GDC members. Editorial supportwas provided by Thor Eglington MSc, RN; Karin SorraBSc, PhD; Lynn Shaw BSc, MSc, PhD; Martin Descar-reaux, DC, PhD. Funding was provided by the Cana-dian Chiropractic Association (CCA), Canadian Chi-ropractic Protective Association (CCPA), and provin-cial chiropractic contributions from all provinces ex-cept British Columbia. This work was sponsored byThe CCA and The CFCREAB. The GDC declares noconflicts of interest.

References

[1] D.G. Altman, K.F. Schulz, D. Moher et al., The revised CON-SORT statement for reporting randomized trials: explanationand elaboration, Ann Intern Med 134(8) (2001), 663–694.

[2] E. Anderson-Peacock, J.S. Blouin, R. Bryans et al., Chiro-practic clinical practice guideline: evidence–based treatmentof adult neck pain not due to whiplash, J Can Chiropr Assoc49(3) (2005), 158–209.

[3] K. Atherton, N.J. Wiles, F.E. Lecky et al., Predictors of per-sistent neck pain after whiplash injury, Emerg Med J 23(3)(2006), 195–201.

[4] J.E. Bolton and B.K. Humphreys, The Bournemouth Ques-tionnaire: a short-form comprehensive outcome measure, II,Psychometric properties in the neck pain patients, J Manipu-lative Physiol Ther 25(3) (2002), 141–148.

[5] A.D. Bonk, R. Ferarri, G.D. Giebel et al., Prospective, ran-domized, controlled study of activity versus collar and the nat-ural history for whiplash injury in Germany, J MusculoskeletalPain 8(1–2) (2000), 123–132.

[6] G.E. Borchgrevink, A. Kaasa, D. McDonagh et al., Acutetreatment of whiplash neck sprain injuries. A randomized trialof treatment during the first 14 days after a car accident, Spine23(1) (1998), 25–31.

[7] R.J. Brison, L. Hartling, S. Dostaler et al., A randomizedcontrolled trial of an educational intervention to prevent thechronic pain of whiplash associated disorders following rear-end motor vehicle collisions, Spine 30(16) (2005), 1799–1807.

[8] R. Bryans, E. Anderson-Peacock, M. Descarreaux et al., Prac-tice Guide for the Management of Whiplash-Associated Dis-orders in Adults, CPG Initiative, (2010).

[9] R. Bryans, Whiplash – A Practitioner’s Guide to Understand-ing Whiplash Associated Disorders (WAD), Canadian Chiro-practic Association, (1999).


[10] L. Bunketorp, M. Lindh, J. Carlsson and E. Stener-Victorin,The effectiveness of a supervised physical training modeltailored to the individual needs of patients with whiplash-associated disorders—a randomized controlled trial, Clin Re-habil 20(3) (2006), 201–217.

[11] L.J. Carroll, S. Hogg-Johnson, G. van der Velde et al., Courseand prognostic factors for neck pain in the general population:results of the Bone and Joint Decade 2000-2010 Task Forceon Neck Pain and Its Associated Disorders, Spine 33(4 suppl)(2008), S75–S82.

[12] P. Cote, S. Hogg-Johnson, J.D. Cassidy et al., The associationbetween neck pain intensity, physical functioning, depressivesymtomatology and time-to-claim-closure after whiplash, JClin Epidemiol 54(3) (2001), 275–286.

[13] P. Cote, S. Hogg-Johnson, J.D. Cassidy et al., Initial pat-terns of clinical care and recovery from whiplash injuries:a population-based cohort study, Arch Intern Med 165(19)(2005), 2257–2263.

[14] P. Cote, S. Hogg-Johnson, J.D. Cassidy et al., Early aggressivecare and delayed recovery from whiplash: isolated finding orreproducible result? Arthritis Rheum 57(5) (2007), 861–868.

[15] I.D. Coulter and P.G. Shekelle, Chiropractic in North Ameri-ca: a descriptive analysis, J Manipulative Physiol Ther 28(2)(2005), 83–89.

[16] J.R. Crawford, R.J.K. Khan and G.W. Varley, Early manage-ment and outcome following soft tissue injuries of the neck –a randomized controlled trial, Injury 35 (2004), 891–895.

[17] D.C. Des Jarlais, C. Lyles and N. Crepaz, Improving the re-porting quality of nonrandomized evaluations of behavioraland public health interventions: the TREND statement, Am JPublic Health 94(3) (2004), 361–366.

[18] R. Ferarri, B.H. Rowe and S.R. Majumdar et al., Simple ed-ucational intervention to improve the recovery from acutewhiplash: results of a randomized, controlled trial, AcadEmerg Med 12(8) (2005), 699–706.

[19] V. Fialka, E. Preisinger and A. Bohler, Zur physikalischendiagnostik und physikalishen therapie der distorsio columnaevertebralis cervicalis, Z Phys Med Baln Med Klim 18 (1989),390–397.

[20] D. Fitz-Ritson, Phasic exercises for cervical rehabilitation after“whiplash” trauma, J Manipulative Physiol Ther 18(1) (1995),21–24.

[21] S.M. Foreman and A.C. Croft, in: Whiplash Injuries: TheCervical Acceleration/Deceleration Syndrome, (Vol. 3), Bal-timore: Lippincott Williams and Wilkins, 2001.

[22] P. Gennis, L. Miller, E.J. Gallagher et al., The effect of soft cer-vical collars on persistent neck pain in patients with whiplashinjury, Acad Emerg Med 3(6) (1996), 568–573.

[23] J.M. Grimshaw, L. Shirran, R. Thomas et al., ChangingProvider Behaviour, An Overview of Systematic Reviews ofInterventions, Medical Care 39(8S2) (2001), II2–II45.

[24] G.H. Guyatt, D.L. Sackett, J.C. Sinclair et al., Users’ guidesto the medical literature, IX, A method for grading health carerecommendations, Evidence-Based Medicine Working Group,JAMA 274(22) (1995), 1800–1804.

[25] G.H. Guyatt, J. Sinclair, D.J. Cook and P. Glasziou, Users’guides to the medical literature, XVI, How to use a treatmentrecommendation, Evidence-Based Medicine Working Groupand the Cochrane Applicability Methods Working Group,JAMA 281(19) (1999), 1836–1843.

[26] J. Guzman, E.L. Hurwitz, L.J. Carroll et al., A new conceptualmodel of neck pain: linking onset, course, and care: the Boneand Joint Decade 2000–2010 Task Force on Neck Pain and ItsAssociated Disorders, Spine 33(4 Suppl) (2008), S14–S23.

[27] S. Haldeman, L. Carroll, J.D. Cassidy et al., The Bone andJoint Decade 2000–2010 Task Force on Neck Pain and ItsAssociated Disorders: executive summary, Spine 33(4 suppl)(2008), S5–S7.

[28] H. Heikkila, E. Heikkila and M. Eisemann, Predictive fac-tors for the outcome of a multidisciplinary pain rehabilitationprogramme on sick-leave and life satisfaction in patients withwhiplash trauma and other myofascial pain: a follow-up study,Clin Rehabil 12(6) (1998), 487–496.

[29] O. Hendriks and A. Horgan, Ultra-reiz current as an adjunctto standard physiotherapy treatment of the acute whiplash pa-tient, Physiotherapy Ireland 17(1) (1996), 3–7.

[30] E.J. Hendriks, G.G. Scholten-Peeters, D.A. van der Windt etal., Prognostic factors for poor recovery in acute whiplashpatients, Pain 114(3) (2005), 408–416.

[31] E.L. Hurwitz, E.J. Carragee, G. van der Velde et al., Treatmentof neck pain: noninvasive interventions: results of the Boneand Joint Decade 2000–2010 Task Force on Neck Pain and ItsAssociated Disorders, Spine 33(4 Suppl) (2008), S123–S152.

[32] IASP. IASP Pain Terminology. http://www.iasp-pain.org/AM/Template.ctm?Section=Pain Definition&Template=/CM/HTMLDisplay.cfm&ContentID=1728. Accessed May2009, (2009).

[33] N. Jacobson, D. Butterill and P. Goering, Development ofa framework for knowledge translation: understanding usercontext, J Health Serv Res Policy 8(2) (2003), 94–99.

[34] A. Jordan and K. Ostergaard, Rehabilitation of neck/shoulderpatients in primary health care clinics, J Manipulative PhysiolTher 19(1) (1996), 32–35.

[35] T.M. Kay, A. Gross, C. Goldsmith et al., Exercises for mechan-ical neck disorders, Cochrane Database Syst Rev (2005)(3):CD004250.

[36] A. Kongsted, E. Querma, H. Kasch et al., Neck collar, “act-as-usual” or active mobilization for whiplash injury? A ran-domized parallel-group trial, Spine 32(6) (2007), 618–626.

[37] P. Kroeling, A, Gross and P.E. Houghton, Electrotherapyfor neck disorders, Cochrane Database Syst Rev (2005)(2):CD004251.

[38] V. Kumar, A.K. Abbas and N Fausto, Tissue Renewal andRepair: Regeneration, Healing, and Fibrosis, in: PathologicBasis of Disease, (Vol. 7), Robbins and Cotran, 2004, pp. 87–118.

[39] C. Liebenson, Functional reactivation for neck pain patients,J Bodywork, Movement Ther 6(1) (2002), 59–66.

[40] J. Lomas, Improving research dissemination and uptake inthe health sector: Beyond the sound of one hand clapping,McMaster University Centre for Health Economics and PolicyAnalysis, (1997).

[41] G.A. Malanga, Cervical Flexion-Extension/Whiplash Injuries,Philadelphia: Hanley and Belfus, (1998).

[42] L.A. McKinney, Early mobilization and outcome in acutesprains of the neck, BMJ 299(6706) (1989), 1006–1008.

[43] L.A. McKinney, J.O. Dorman and M. Ryan, The role of phys-iotherapy in the management of acute neck sprains followingroad-traffic accidents, Arch Emerg Med 6(1) (1989), 27–33.

[44] K. Mealy, H. Brennan and G.C. Fenelon, Early mobilizationof acute whiplash injuries, Br Med J (Clin Res Ed) 292(6521)(1986), 656–657.

[45] R. Melzack, The McGill pain questionnaire: from descriptionto measurement, Anesthesiology 103(1) (2005), 199–202.

[46] H. Merskey and N. Bogduk, eds, IASP Task Force on Taxon-omy, Classification of Chronic Pain: Descriptions of ChronicPain Symptoms and Definition of Pain Terms, (Vol. 2), Seattle:IASP Press, 1994, pp. 209–214.


[47] D. Moher, K.F. Schulz and D.G. Altman, The CONSORTstatement: revised recommendations for improving the qual-ity of reports of parallel-group randomized trials, Lancet357(9263) (2001), 1191–1194.

[48] D. Murphy, Conservative Management of Cervical Spine Syn-dromes, McGraw Hill Medical 1 (1999), 747 pp.

[49] OCEBM. Oxford Centre for Evidence-Based Medicine Levelsof Evidence (May 2001). 2001; http://www.cebm.net/levelsof evidence.asp. Accessed 2008, Oxford UK.

[50] A. Oliveira, R. Gevirtz and D. Hubbard, A psycho-educationalvideo used in the emergency department provides effectivetreatment for whiplash injuries, Spine 31(15) (2006), 1652–1657.

[51] P.J. Osterbauer, K.L. Derickson, J.D. Peles et al., Three-dimensional head kinematics and clinical outcome of patientswith neck injury treated with spinal manipulative therapy: apilot study, J Manipulative Physiol Ther 15(8) (1992), 501–511.

[52] B.H. Pennie and L.J. Agambar, Whiplash injuries, A trial ofearly management, J Bone Joint Surg Br 72(2) (1990), 277–279.

[53] L. Provinciali, M. Baroni, L. Illuminati and M.G. Ceravolo,Multimodal treatment to prevent the late whiplash syndrome,Scand J Rehabil Med 28(2) (1996), 105–111.

[54] A.A Rodriquez, K.P. Barr and S.P. Burns, Whiplash: patho-physiology, diagnosis, treatment, and prognosis, Muscle Nerve29(6) (2004), 768–781.

[55] A.A. Rodriquez, W.J. Bilkey and J.C. Agre, Theraputic exer-cise in chronic neck and back pain, Arch Phys Med Rehabil73(9) (1992), 870–875.

[56] M. Rosenfeld, A. Seferiadis, J. Carlsson and R. Gunnarsson,Active intervention in patients with whiplash-associated disor-ders improves long-term prognosis: a randomized controlledclinical trial, Spine 28(22) (2003), 2491–2498.

[57] D.L. Sackett, S. Straus and S. Richardson, Evidence-BasedMedicine: How to Practice and Teach EBM, (Vol. 2), London,UK: Churchill Livingstone, 2000.

[58] H. Sarig-Bahat, Evidence for exercise therapy in mechanicalneck disorders, Man Ther 8(1) (Feb 2003), 10–20.

[59] M. Schnabel, R. Ferrari, T. Vassiliou and G. Kaluza, Random-ized, controlled outcome study of active mobilization com-pared with collar therapy for whiplash injury, Emerg Med J21(3) (2004), 306–310.

[60] G.G. Scholten-Peeters, A.P. Verhagen, G.E. Bekkering et al.,Prognostic factors of whiplash-associated disorders: a sys-tematic review of prospective cohort studies, Pain 104(1–2)(2003), 303–322.

[61] G.G. Scholten-Peeters, C.W. Neeleman-van der Steen, D.A.van der Windt et al., Education by general practitioners oreducation and exercises by physiotherapists for patients withwhiplash-associated disorders? A randomized clinical trial,Spine 31(7) (2006), 723–731.

[62] M. Sherer, J.E. Maddux, B. Mercadante et al., The self – effica-cy scale: construction and validation, Psychological Reports51 (1982), 663–671.

[63] K. Skinner, Developing a tool to measure knowledge ex-change outcomes, Canadian Journal of Program Evaluation22 (2007), 49–73.

[64] R.E. Slavin, Best evidence synthesis: an intelligent alternativeto meta-analysis, J Clin Epidemiol 48(1) (1995), 9–18

[65] A. Soderlund and P. Lindberg, Cognitive behavioral compo-nents in physiotherapy management of chronic whiplash as-sociated disorders (WAD) – a randomized group study, Phys-iotherapy Theory and Practice 17(4) (2001), 229–239.

[66] A. Soderlund, C. Olerud and P. Lindberg, Acute whiplash-associated disorders (WAD): the effects of early mobilizationand prognostic factors in long-term symptomatology, Clin Re-habil 14(5) (2000), 457–467.

[67] H.J.S. Speziale and D.R. Carpenter, Qualitative Research inNursing: Advancing the Humanistic Imperative, (Vol. 3),Philadelphia: Lippincott Williams and Wilkens, 2003.

[68] W.O. Spitzer, M.L. Skovron, L.R. Salmi et al., Scientificmonograph of the Quebec Task Force on Whiplash-AssociatedDisorders: redefining “whiplash” and its management, Spine20(8 Suppl) (1995), 1S–73S.

[69] M. Sterling and J. Kenardy, Physical and psychological as-pects of whiplash: Important considerations for primary careassessment, Man Ther 13(2) (2008), 93–102.

[70] Y. Sterner, M. Lofgren, V. Nyberg et al., Early interdisciplinaryrehabilitation programme for whiplash associated disorders,Disabil Rehabil 23(10) (2001), 422–429.

[71] M.J. Stewart, C.G. Maher, K.M. Refshauge et al., Randomizedcontrolled trial of exercise for chronic whiplash-associateddisorders, Pain 128(1–2) (2007), 59–68.

[72] I.G. Stiell, C.M. Clement, R.D. McKnight et al., The CanadianC-spine rule versus the NEXUS low-risk criteria in patientswith trauma, N Engl J Med 349(26) (2003), 2510–2518.

[73] I.G. Stiell, G.A. Wells, K.L. Vandemheen et al., The CanadianC-spine rule for radiography in alert and stable trauma patients,JAMA 286(15) (2001), 1841–1848.

[74] M.J. Sullivan, S.R. Bishop and J. Pivik, The pain Catastro-phizing Scale: development and validation, Psychol Assess7(4) (1995), 524–532.

[75] A.A Vendrig, P.F. van Akkerveeken and K.R. McWhorter,Results of a multimodal treatment program for patients withchronic symptoms after a whiplash injury of the neck, Spine25(2) (2000), 238–244.

[76] A.P. Verhagen, G.G. Scholten-Peeters, R.A. de Bie andS.M. Bierma-Zeinstra, Conservative treatments for whiplash,Cochrane Database Syst Rev (2004)(1):CD003338.

[77] M.N Woodward, J.C. Cook, M.F. Gargan and G.C. Bannister,Chiropractic treatment of chronic ‘whiplash’ injuries, Injury27(9) (1996), 643–645.

Copyright of Work is the property of IOS Press and its content may not be copied or emailed to multiple sites or

posted to a listserv without the copyright holder's express written permission. However, users may print,

download, or email articles for individual use.

IOS Press A systematic review of chiropractic management ......WAD is needed to enable persons to...

Documents

Transcript of IOS Press A systematic review of chiropractic management ......WAD is needed to enable persons to...