Conservative treatments for whiplash

Whiplash is defined as an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions or during diving, among other mishaps.

Whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms from Grade 0 (no complaints or physical signs) to Grade 4 (fracture or dislocation). Whiplash-associated disorders have been reported in 70 in 100,000 inhabitants in a Canadian province, to 188 to 325 per 100,000 inhabitants in The Netherlands. Conservative treatments (for example, physiotherapy, acupuncture, or a collar) are the most common treatment options for whiplash patients, but the evidence supporting their effectiveness remains conflicting.

We included 23 studies (2344 participants with WAD Grades 1 or 2), nine of which were new for this update. Overall, the methodological quality was poor and the studies included populations and interventions that were too different to pool. Two studies examined treatments for patients with chronic pain (longer than three months), two looked at subacute pain (four to six weeks), two were unclear (but one was probably chronic), and the rest looked at patients with acute symptoms of less than three weeks.

In 11 studies, an active treatment approach (treatment strategy including exercises or advice to 'act as usual') was compared to a passive strategy, no treatment or was an additional treatment. Eight studies compared an active intervention with a passive one (the patient received a treatment such as advice to rest and wear a neck collar, an educational video, electrotherapy, manipulation, hot and cold packs, traction, or acupuncture). Eight studies compared an intervention with a placebo or no treatment. In seven studies, two active treatments were compared against each other and in one, a passive intervention was compared to injections.

Since we were unable to pool any of the studies, we remain unable to either support or refute the effects of conservative treatments for acute, subacute or chronic whiplash-associated disorders with the current evidence.

Authors' conclusions: 

The current literature is of poor methodological quality and is insufficiently homogeneous to allow the pooling of results. Therefore, clearly effective treatments are not supported at this time for the treatment of acute, subacute or chronic symptoms of whiplash-associated disorders.

Read the full abstract...

Many treatments are available for whiplash patients but there is little scientific evidence for their accepted use. Patients with whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms from Grade 0 (no complaints or physical signs) to Grade 4 (fracture or dislocation).


To assess the effectiveness of conservative treatment for patients with whiplash injuries rated as Grades 1 or 2 (neck and musculoskeletal complaints).

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2006, Issue 3), MEDLINE, CINAHL, PsycINFO, and PEDro to November 2006 and screened references of identified randomised trials and relevant systematic reviews.

Selection criteria: 

We selected randomised controlled trials published in English, French, German or Dutch, that included patients with a whiplash-injury, conservative interventions, outcomes of pain, global perceived effect or participation in daily activities.

Data collection and analysis: 

Two authors independently assessed the methodological quality using the Delphi criteria and extracted the data onto standardised data-extraction forms. We did not pool the results because of the heterogeneity of the population, intervention and outcomes and lack of data. A pre-planned stratified analysis was performed for three different comparisons.

Main results: 

Twenty-three studies (2344 participants) were included in this update, including nine new studies. A broad variety of conservative interventions were evaluated. Two studies included patients with chronic symptoms (longer than three months), two included subacute (four to six weeks) symptoms, two had undefined duration of symptoms, and 17 studied patients with acute (less than three weeks) symptoms. Only eight studies (33.3%) satisfied one of our criteria of high quality, indicating overall, a poor methodological quality. Interventions were divided into passive (such as rest, immobilisation, ultrasound, etc) and active interventions (such as exercises, act as usual approach, etc.) and were compared with no treatment, a placebo or each other.

Clinical and statistical heterogeneity and lack of data precluded pooling. Individual studies demonstrated effectiveness of one treatment over another, but the comparisons were varied and results inconsistent. Therefore, the evidence neither supports nor refutes the effectiveness of either passive or active treatments to relieve the symptoms of WAD, Grades 1 or 2.