To evaluate effectiveness of physiotherapy management in patients experiencing whiplash associated disorder II, on clinically relevant outcomes in the short and longer term.
Systematic review and meta-analysis. Two reviewers independently searched information sources, assessed studies for inclusion, evaluated risk of bias and extracted data. A third reviewer mediated disagreement. Assessment of risk of bias was tabulated across included trials. Quantitative synthesis was conducted on comparable outcomes across trials with similar interventions. Meta-analyses compared effect sizes, with random effects as primary analyses.
Predefined terms were employed to search electronic databases. Additional studies were identified from key journals, reference lists, authors and experts.
Eligibility criteria for selecting studies
Randomised controlled trials (RCTs) published in English before 31 December 2010 evaluating physiotherapy management of patients (>16 years), experiencing whiplash associated disorder II. Any physiotherapy intervention was included, when compared with other types of management, placebo/sham, or no intervention. Measurements reported on ≥1 outcome from the domains within the international classification of function, disability and health, were included.
21 RCTs (2126 participants, 9 countries) were included. Interventions were categorised as active physiotherapy or a specific physiotherapy intervention. 20/21 trials were evaluated as high risk of bias and one as unclear. 1395 participants were incorporated in the meta-analyses on 12 trials. In evaluating short term outcome in the acute/sub-acute stage, there was some evidence that active physiotherapy intervention reduces pain and improves range of movement, and that a specific physiotherapy intervention may reduce pain. However, moderate/considerable heterogeneity suggested that treatments may differ in nature or effect in different trial patients. Differences between participants, interventions and trial designs limited potential meta-analyses.
Inconclusive evidence exists for the effectiveness of physiotherapy management for whiplash associated disorder II. There is potential benefit for improving range of movement and pain short term through active physiotherapy, and for improving pain through a specific physiotherapy intervention.
Physiotherapy intervention is recommended in whiplash associated disorder II, although the most beneficial intervention and the effectiveness of physiotherapy management are unclear.
Systematic reviews have not focused on whiplash associated disorder II, which represents approximately 93% of patients presenting for management post-whiplash injury.
The objective of this systematic review was to evaluate the effectiveness of physiotherapy management in patients experiencing whiplash associated disorder II, on clinically relevant outcomes in the short and longer term.
This systematic review demonstrates inconclusive very low/low quality evidence for the effectiveness of physiotherapy management for whiplash associated disorder II.
There is potential benefit for improving pain and range of movement short term through active physiotherapy and for improving pain through specific physiotherapy interventions.
This potential benefit merits further consideration in a properly powered clinical trial with attention to ensure low risk of bias.
Strengths and limitations of this study
The strengths of this review are its focus to physiotherapy intervention and the most common whiplash associated disorder II classification requiring physiotherapy intervention.
A limitation is that differences between participants, interventions and trial designs limited potential meta-analyses.
Surprisingly, no chronic interventions were comparable for analysis, considering the high number of patients experiencing chronicity with whiplash associated disorder.