NEW MULTI-DISCIPLINARY CLINICAL GUIDELINES FOR ACUTE AND CHRONIC WHIPLASH-ASSOCIATED -DISORDERS DEVELOPED USING THE GRADE PROCESS- PART 1- TREATMENT RECOMMENDATIONS

C. Papic¹, T. Rebbeck², L. Chia², I.D. Cameron³

¹University of New England, School of Science and Technology, Armidale, Australia, ²University of Sydney, Faculty of Medicine and Health, School of Health Sciences, Sydney, Australia, ³The University of Sydney & Northern Sydney Local Health District, John Walsh Centre for Rehabilitation Research, Kolling Institute, St Leonards, Australia

Background: People with whiplash associated disorders (whiplash) have poor outcomes and those with poor outcomes contribute to the highest rehabilitation costs in many compensable settings. In Australia, despite two decades of guideline development and implementation, gaps remain in the delivery of evidence-based care. Whilst guideline–based advice and exercise are provided on some occasions by some health professions, in the majority of cases, optimal care is delayed or simply not provided. Further, until now, only acute guidelines have been developed, with little guidance on management for chronic whiplash.

Purpose: This project aimed to develop new multi-disciplinary guidelines for both acute and chronic whiplash associated disorders following i) a robust process recommended by the NHMRC in Australia and ii) the GRADE process to develop recommendations for treatment. The multi-disciplinary process aimed to ensure key stakeholders likely to implement recommendations were involved from the commencement of the project.

Methods: Following the NHMRC guidelines, a multidisciplinary committee was convened comprising key stakeholders from clinical professions (e.g. Physiotherapy, General Practice, Physicians, Psychology, Chiropractic, Exercise Physiology), research experts, insurer, legal, government regulator and consumer representatives. A systematic review was performed by our team to retrieve randomised controlled trials for both acute and chronic whiplash. An electronic search for trials was performed from the end of the previous guidelines (2007) until October 2022. The guideline committee determined prioritised PICO (Population, Intervention, Comparison, Outcome) questions to be answered. Trials from the existing guidelines together with those retrieved from the systematic review meeting the PICO questions were meta-analysed and/or summarised narratively. The GRADE “certainty of evidence” and “evidence to decision frameworks” were followed by the guideline committee to determine treatment recommendations. Once prognostic and assessment sections are complete, the guideline will then undergo external and NHMRC review.

Results: The guideline committee comprised 18 members from the above stakeholder groups. Twenty-six PICO questions were prioritised to undergo the GRADE process and form recommendations with 44 trials for acute and 19 trials for chronic WAD included. Recommendations were primarily conditional or neutral, largely due to low certainty of evidence. Conditional recommendations FOR the intervention included active and conservative interventions such as; psychologically informed exercise, neck-specific exercise, education, psychological interventions (e.g., trauma focussed CBT), simple analgesia and NSAID’s. Neutral recommendations with more stringent implementation considerations were made for treatments such as; immobilisation with soft-collar, massage, pregabalin, opioids, and radiofrequency neurotomy. Conditional recommendations AGAINST the intervention were made for invasive and passive treatments such as; surgery, cervical high-velocity thrust manipulation, electrotherapy, and trigger point needling. Strong recommendations were made AGAINST injection techniques (e.g., botulinum toxin-A and steroids).

Conclusions: Active and conservative interventions had the highest recommendations and many of these are able to be implemented by physical therapists. In contrast, more passive and invasive interventions were not recommended.

Implications: The robust and national guideline development process involving key stakeholders is recommended to increase acceptance and adoption by these stakeholders. Physical therapists have the skills to implement many of these recommendations, whilst training may be required to implement others.

Funding acknowledgements: State Insurance Regulatory Authority (SIRA) of NSW, Australia.

Keywords:
whiplash
clinical guidelines
GRADE

Topics:
Musculoskeletal: spine
Pain & pain management
Disability & rehabilitation

Did this work require ethics approval? No

Reason: This was a clinical guideline developed from a systematic review of the evidence.