Treatment strategies for chronic cases

Abstract

This paper addresses the treatment of chronic somatic pain after whiplash injury; that is, pain referred to the head, neck, shoulder girdle and upper limb from somatic structures. There is a dearth of literature regarding the treatment of other chronic whiplash-associated symptoms such as dizziness, visual disturbance, and cognitive impairment, which precludes a literature synthesis. Nor will this paper address the treatment of radicular pain, for the diagnosis and treatment of true radiculopathy generate little controversy, and are adequately covered in the neurological and neurosurgical literature. The majority of patients who report acute whiplash-associated disorder (WAD) are asymptomatic 12 months later. Only 15-20% of patients remain symptomatic, and only about 5% are severely affected. However, it is the latter group that constitutes the major burden to insurers and to health care resources. The most cost-efficient treatment strategy for any condition is one that has perfect efficacy, that is, one that completely relieves the condition and prevents its sequelae. The challenge is to develop such a strategy for chronic pain after whiplash. The treatment strategy should be based on scientific evidence of the highest quality. Unfortunately, only one Grade I study has been attempted. The Quebec Task Force on WAD undertook a systematic review of the pre-1994 literature addressing WAD. Of 10,382 potentially relevant articles, only 1,204 met preliminary screening criteria, and only 62 were both relevant and scientifically acceptable. With respect to treatment of chronic cases, there was only one Grade II paper that specifically addressed WAD patients (and it had a negative result); a small handful of lesser quality papers addressed various treatments of chronic neck pain of unspecified aetiology. The task force recommended that, if patients had residual symptoms or incapacity after six months, they be sent to a multidisciplinary consultation with health care professionals including doctor, physiotherapist, occupational therapist, and psychologist. The recommendation was not based on any evidence supporting the efficacy of multidisciplinary pain clinics for chronic WAD, but rather, on consensus in the absence of evidence. Consensus is vulnerable to a multitude of biases and stakeholder influences. It should be replaced as soon as quality evidence emerges. So how far have we come since 1994? Not far enough. Let us look at levels of evidence for the various treatments which have been advocated for chronic WAD.