National Guideline Clearinghouse | Expert Commentaries: Does More Add Up to Less? A Review of a Guideline on Whiplash Associated Disorders

September 13, 2010

Does More Add Up to Less? A Review of a Guideline on Whiplash Associated Disorders

By: Anthony J. Lisi, DC

Related Guideline: Management of whiplash associated disorders.
National Guideline Clearinghouse | Management of whiplash associated disorders.

Users of clinical practice guidelines turn to these resources, in part, to reduce inappropriate variations in care. The expectation assumes that a thorough, systematic synthesis of data will yield a product suited to consistently influence case management decisions across populations, providers, and patients. Yet guidelines themselves are of varying methodologies and perspectives; thus, a reader consulting two guidelines on a given topic may likely encounter substantially different recommendations (1).

The International Chiropractors Association of California Guideline on Management of Whiplash Associated Disorders (WAD) represents a recent effort to bring order to the care of patients suffering from this specific neck condition. However, key areas of the Guideline conflict with other current evidence syntheses, and this may result in users facing more, rather than less, uncertainty when attempting to apply these recommendations.

A central component of the Guideline is a recommended treatment strategy for WAD that proposes both treatment options and treatment duration. Among the recommended options are manual therapies, exercises, and education. This is consistent with research demonstrating the short term effectiveness of manual mobilization combined with exercises and educational videos encouraging exercise and return to activity (2). Yet, the Guideline also recommends various physical modalities (electrotherapy, traction, and ultrasound) that others have reported as lacking evidence of benefit (3-5). Furthermore, although the Guideline does cite the work of Hurwitz et al., it seems to overlook the authors’ conclusion that manual therapies, exercises, and education alone appear more beneficial than physical modalities or usual care (2).

The Guideline also provides a recommended treatment frequency and duration strategy of up to 76 treatment sessions within 56 weeks. This contrasts with other work reporting no evidence that a longer, as opposed to shorter, duration of care improves prognosis for neck pain disorders in general (2) or for whiplash in particular (6). When considering manipulation and mobilization for mechanical neck disorders, low quality evidence indicates that relief for both acute and chronic neck pain was achieved after one to four treatment sessions (7). This does not imply that the maximum benefit is attained after one to four sessions. Low quality evidence from one small trial of chronic cervicogenic headache suggests that nine to 12 sessions may provide greater pain relief and improvement in neck-related disability than three sessions (7). However, the optimal dosing approach for manual therapies in general remains unknown. On the other hand, there is consistent evidence that frequent, early use of health care and psychological factors, such as passive coping, correlate with poorer recovery (8). In the general neck pain population, psychosocial factors such as coping pattern and the need to socialize were identified as the strongest factors associated with poor prognosis (9). Thus, one must consider the real possibility that frequent applications of a passive modality by an empathetic provider may be the worst approach for many WAD patients.

All stakeholders in healthcare — from policy makers to patients — face an ever increasing amount of medical information. Clinical practice guidelines provide readers with an accessible summary of this information as it applies to patient care. However, clinicians presented with conflicting guidelines will need to carefully consider the primary literature, along with their own clinical experience and individual patient factors, when making treatment decisions.

Author

Anthony J. Lisi, DC
VHA Chiropractic Service, Office of Rehabilitation Services, West Haven, CT

Disclaimer

Dr. Lisi is the Director, Chiropractic Program, Veterans Health Administration and Chief of the Chiropractic Section for the VA Connecticut Healthcare System in West Haven, CT. He is also an Associate Professor at the University of Bridgeport College of Chiropractic in Connecticut. This commentary is a reflection of his views and opinions and does not necessarily reflect the official position of the VHA or the University of Bridgeport College of Chiropractic.

The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Guideline Clearinghouse™ (NGC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor, ECRI Institute.

Potential Conflicts of Interest

Dr. Lisi declared no potential conflicts of interest with respect to this expert commentary.

References

1.Chou R. Using evidence in pain practice: Part II: Interpreting and applying systematic reviews and clinical practice guidelines. Pain Med. 2008 Jul-Aug;9(5):531-41.
2.Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008 Feb 15;33(4 Suppl):S123-52.
3.Kroeling P, Gross A, Goldsmith CH, Burnie SJ, Haines T, Graham N, Brant A. Electrotherapy for neck pain. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD004251. DOI: 10.1002/14651858.CD004251.pub4.
4.Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines T, Burnie SJ, Peloso PMJ. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006408. DOI: 10.1002/14651858.CD006408.pub2.
5.Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash-associated disorders--part I: Non-invasive interventions. Pain Res Manag. 2005 Spring;10(1):21-32.
6.Shaw L, Descarreaux M, Bryans R, Duranleau M, Marcoux H, Potter B, Ruegg R, Watkin R, White E. A systematic review of chiropractic management of adults with Whiplash-Associated Disorders: recommendations for advancing evidence-based practice and research. Work. 2010;35(3):369-94.
7.Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Manipulation or mobilisation for neck pain. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004249. DOI: 10.1002/14651858.CD004249.pub3.
8.Carroll LJ, Holm LW, Hogg-Johnson S, Côté P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM, Guzman J; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008 Feb 15;33(4 Suppl):S83-92.
9.Carroll LJ, Hogg-Johnson S, van der Velde G, Haldeman S, Holm LW, Carragee EJ, Hurwitz EL, Côté P, Nordin M, Peloso PM, Guzman J, Cassidy JD; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008 Feb 15;33(4 Suppl):S75-82.

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National Guideline Clearinghouse | Expert Commentaries: Does More Add Up to Less? A Review of a Guideline on Whiplash Associated Disorders