A P Verhagen1, G G Peeters, R A de Bie, R A Oostendorp. 1. Department of General Practice, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, Netherlands. Verhagen@hag.fgg.eur.nl
Abstract
BACKGROUND: Many treatments are available for whiplash-patients, but to date, no evidence exists for their effectiveness. OBJECTIVES: The objective of this systematic review was to assess the efficacy of conservative treatment in patients with whiplash-injuries (rated as Whiplash-Associated Disorders [WAD] I or II). SEARCH STRATEGY: A computerized literature search of Medline, Embase, Cinahl, Psychlit and the Cochrane Controlled Trial Register through June 1998 was carried out. We also screened reference lists of publications of identified randomized trials and relevant systematic reviews. SELECTION CRITERIA: Studies were selected for inclusion if they fit the following criteria: design was a (randomized) clinical trial (RCT); all patients had suffered a whiplash-injury; the type of intervention was a conservative one; pain, global perceived effect, or participation in daily activities was used as one of the outcome measures; and the publication was written in English, French, German or Dutch. DATA COLLECTION AND ANALYSIS: The methodological quality of the studies was independently assessed by two reviewers using the Maastricht-Amsterdam list. Three quality scores were calculated using this criteria list: the Overall methodological Quality Score, the Internal Validity Score and the Delphi Quality Score. The conclusion of the review was based on articles that scored a quality score of at least 50 percent of the maximum available score on two out of three quality scores. MAIN RESULTS: Eleven studies met the inclusion criteria. A broad variety of conservative interventions were evaluated, and only one study was performed in chronic whiplash patients. Only three studies satisfied at least 50 percent on two out of three quality scores indicating poor overall methodological quality. A high rank correlation was observed among the three methods of quality. Because of the heterogeneity of patient selection, interventions and outcome measures, no statistical pooling was performed. This review indicates that active treatments show a beneficial effect on at least one of the primary outcome measures, preferably pain. REVIEWER'S CONCLUSIONS: It appears that "Rest makes rusty." In other words, rest and immobilization using collars are not recommended for the treatment of whiplash, while active interventions, such as advice to 'maintain usual activities' might be effective in whiplash-patients. Nevertheless, caution is needed when attempting to draw conclusions regarding the efficacy of conservative treatments in whiplash-patients, because of the paucity of high-quality studies. No conclusions can be drawn about the most effective therapy for chronic whiplash-patients because only one low quality trial was identified.
BACKGROUND: Many treatments are available for whiplash-patients, but to date, no evidence exists for their effectiveness. OBJECTIVES: The objective of this systematic review was to assess the efficacy of conservative treatment in patients with whiplash-injuries (rated as Whiplash-Associated Disorders [WAD] I or II). SEARCH STRATEGY: A computerized literature search of Medline, Embase, Cinahl, Psychlit and the Cochrane Controlled Trial Register through June 1998 was carried out. We also screened reference lists of publications of identified randomized trials and relevant systematic reviews. SELECTION CRITERIA: Studies were selected for inclusion if they fit the following criteria: design was a (randomized) clinical trial (RCT); all patients had suffered a whiplash-injury; the type of intervention was a conservative one; pain, global perceived effect, or participation in daily activities was used as one of the outcome measures; and the publication was written in English, French, German or Dutch. DATA COLLECTION AND ANALYSIS: The methodological quality of the studies was independently assessed by two reviewers using the Maastricht-Amsterdam list. Three quality scores were calculated using this criteria list: the Overall methodological Quality Score, the Internal Validity Score and the Delphi Quality Score. The conclusion of the review was based on articles that scored a quality score of at least 50 percent of the maximum available score on two out of three quality scores. MAIN RESULTS: Eleven studies met the inclusion criteria. A broad variety of conservative interventions were evaluated, and only one study was performed in chronic whiplash patients. Only three studies satisfied at least 50 percent on two out of three quality scores indicating poor overall methodological quality. A high rank correlation was observed among the three methods of quality. Because of the heterogeneity of patient selection, interventions and outcome measures, no statistical pooling was performed. This review indicates that active treatments show a beneficial effect on at least one of the primary outcome measures, preferably pain. REVIEWER'S CONCLUSIONS: It appears that "Rest makes rusty." In other words, rest and immobilization using collars are not recommended for the treatment of whiplash, while active interventions, such as advice to 'maintain usual activities' might be effective in whiplash-patients. Nevertheless, caution is needed when attempting to draw conclusions regarding the efficacy of conservative treatments in whiplash-patients, because of the paucity of high-quality studies. No conclusions can be drawn about the most effective therapy for chronic whiplash-patients because only one low quality trial was identified.