Conservative treatments for whiplash

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Abstract
Our previous review examining conservative treatments for whiplash was published in 2001. Since then, new trials have been published. Whiplash‐associated disorders (WAD) can be classified by the severity of signs and symptoms: WAD Grade 0 indicates no complaints or physical signs; Grade 1 indicates neck complaints but no physical signs; Grade 2 indicates neck complaints and musculoskeletal signs; Grades 3 and 4 indicate neck complaints and neurological signs or fracture/dislocation, respectively. To assess the effectiveness of conservative treatment in patients with WAD Grades 1 or 2. We completed a computerised search of CENTRAL, MEDLINE, EMBASE, CINAHL, PsycLIT, and PEDro, to April 2003. We also screened references of identified trials and relevant systematic reviews. Studies were selected if they were a (randomised) clinical trial, examined patients with a WAD, examined conservative treatments, measured one of: pain, global perceived effect or participation in daily activities, and were published in English, French, German or Dutch. Two authors independently assessed the methodological quality using the Delphi list and extracted the data using standardised forms. Because the population, interventions and outcome measures were heterogeneous, we used a rating system with levels of evidence rather than statistical pooling for the analysis. Clinically relevant improvement was defined as a 15% improvement relative to a control. A pre‐planned stratified analysis was performed in three groups. We found four new studies since the previous review, resulting in 15 studies that met the inclusion criteria. Just one study evaluated patients with chronic WAD. Only three studies satisfied one of our criteria of high quality, indicating overall a poor methodological quality. The broad array of conservative interventions were divided into passive and active interventions and were compared with each other, no treatment, or a placebo group. There was limited evidence that both passive and active interventions seemed to be more effective than no treatment. Contrary to our earlier review, we found conflicting evidence about the effectiveness of active interventions compared to passive ones. All but one study mentioned positive results, but the actual data of the high quality studies were conflicting. When looking at the actual data presented in the current included trials, our conclusion from the previous version of this review, that 'rest makes rusty', can no longer be justified. There is a trend suggesting that active interventions are more effective than passive ones, but no clear conclusion can be drawn. We can draw no conclusion about the most effective therapy for patients with chronic WAD, because only one low quality trial was found.