Background & Aims
Whiplash injury is the most common non-catastrophic road traffic injury and can result in a collection of symptoms and disorders such as pain, dizziness, and psychological distress. Half of people won’t recover following whiplash, developing chronic pain and experiencing long-term interference in daily life[1,2]. Given the incidence of whiplash injury worldwide, costs associated with its rehabilitation and management are significant; £3 billion in the UK[3] and $1 billion in Australia[4] annually. Limited guidance is available for healthcare professionals (HCPs) managing chronic whiplash. Clinical guidelines for whiplash have been developed in Australia since 2000 with chronic whiplash recommendations last published in 2008[5]. A draft 4th edition was developed in 2023[6] with recommendations for both acute and chronic phases. The aim was to provide guidance to HCPs on how to assess and manage people with whiplash, to ensure care provided is timely, effective, cost-effective, and safe.
Methods
The Whiplash Guidelines were developed in accordance with the Australian National Health and Medical Research Council Guideline Standards. A multidisciplinary panel (n=18) was convened and comprised clinicians, researchers, insurers, and consumers. Three systematic reviews were conducted for the assessment, prognosis, and treatment of whiplash. Data were analysed for critical outcomes of neck pain, neck disability, psychological functioning, and non-recovery; certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method[7,8]. Evidence for benefits/harms, resources required, cost-effectiveness, equity, acceptability, and feasibility of the assessment or treatment method were included in the Evidence to Decision Framework[9] and discussed by the panel to inform clinical recommendations and implementation considerations for HCPs. This presentation focusses on recommended care for managing chronic whiplash.
Results
Observational (N=135), prospective cohort (N=6), randomised controlled trial (N=44) studies informed the chronic whiplash recommendations. We recommend HCPs assess neck pain and disability, other symptoms (e.g., sleep disturbance), and factors (neurological assessment, cervical range of motion, and palpation) to establish the whiplash grade. Recommended treatment is education, neck-specific exercises, dizziness-specific exercises, and multimodal physical therapy. Exercise and simple psychological strategies, and multidisciplinary care are indicated in people who present with pain, physical impairment, and psychological distress. HCPs should assess for post-traumatic stress symptoms, depression, and perceived injustice to determine if referral may be required for psychological management, with trauma-focussed cognitive behavioural therapy recommended. If indicated, physical assessments of muscle function, sensorimotor impairment, and sensory hypersensitivity are recommended and should guide treatment direction.
Conclusions
Management of people with chronic whiplash should focus on active physical therapy with an emphasis on developing pain self-efficacy and improving functional outcomes. For those with moderate-to-severe disability and psychological distress, referral to a whiplash specialist and/or for psychological management is recommended and interprofessional communication is critical for effective multidisciplinary collaborative care for these people. Integrated physical and psychological care by HCPs (e.g., physiotherapists) will require education by trained psychologists to effectively prescribe simple psychological strategies such as cognitive behavioural and stress management approaches. Implementation strategies for HCPs involving profession-tailored education on clinical practice recommendations and their implementation is recommended to ensure up-to-date evidence-based care for managing chronic whiplash.
References
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5.TRACsa. (2008). Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders. TRACsa: Trauma and Injury Recovery, Adelaide, Australia.
6.State Insurance Regulatory Authority, Papic, C., Rebbeck, T., Carvalho-e-Silva, A. P., Chia, L., Brown, K., Cameron, I. D., & the Whiplash Guideline Panel: Draft Australian Clinical Guidelines for Health Professionals Managing People with Whiplash-Associated Disorders, Fourth Edition 2023. Sydney, Australia.
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10.Sarrami, P., Armstrong, E., Naylor, J. M., & Harris, I. A. (2017). Factors predicting outcome in whiplash injury: a systematic meta-review of prognostic factors. Journal of Orthopaedics and Traumatology, 18, 9-16.
11.Rebbeck, T., Leaver, A., Bandong, A. N., Kenardy, J., Refshauge, K., Connelly, L., … & Sterling, M. (2016). Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial. Journal of Physiotherapy, 62(2), 111.
12.Björsenius, V., Löfgren, M., & Stålnacke, B. M. (2020). One-year follow-up after multimodal rehabilitation for patients with whiplash-associated disorders. International Journal of Environmental Research and Public Health, 17(13), 4784.
Presenting Author
Christopher Papic
Poster Authors
Christopher Papic
PhD
RECOVER Injury Research Centre, University of Queensland
Lead Author
Trudy Rebbeck
PhD
John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, Australia
Lead Author
Ana Paula Carvalho-e-Silva
PhD
John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, Australia
Lead Author
Lionel Chia
PhD
Postdoctoral Researcher
Lead Author
Katherine Brown
PhD
John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, Australia
Lead Author
Ian Cameron
PhD
John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, Australia
Lead Author
Topics
- Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science