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Three Part Question

In [patients with a neck sprain] is [early neck mobilisation or immobilisation in a soft collar] better at [reducing early and late neck symptoms]?

Clinical Scenario

A 45 year old man attends the emergency department following a road traffic accident. He complains of neck discomfort. He has discomfort on neck movement and clinical examination reveals muscular tenderness. You diagnose a neck sprain (whiplash injury). You wonder whether a early mobilisation is better than immobilisation in a soft collar.

Search Strategy

Medline 1966-06/99 using the OVID interface.
Updated 02/05 using the OVID interface via ATHENS
Original search((exp whiplash injuries OR whiplash.mp OR {[exp neck injuries OR exp neck OR neck.mp] AND [exp sprains and strains OR sprain$.mp OR strain$.mp]}) AND [exp physical therapy OR physiotherapy.mp OR manual therapy.mp OR exp emergency treatment OR exp treatment failure OR exp. treatment outcome OR treatment$.mp Or treat$.mp] AND maximally sensitive RCT filter) LIMIT to human and english.
Update search.
(collar.mp OR bandage.mp OR exp BANDAGES OR splint.mp OR exp SPLINTS OR collar$.mp) AND (cervical.mp OR exp Cervical vertebrae OR exp Neck pain OR exp neck muscles OR exp neck injuries OR exp neck OR neck.mp) AND (exp accidents, traffic or exp whiplash injuries or whiplash.mp or WAD.mp) LIMIT to human english and abstracts

Search Outcome

Original search: 99 papers found of which 94 irrelevant or of insufficient quality for inclusion. The five remaining papers are shown in the table.
Update search: 39 papers found of which 4 new papers were added to the BET.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mealy K et al UK 1986	61 patients with acute whiplash injury Cervical collar vs early active mobilisation	PRCT	Cervical movement at 8 weeks	Significantly better in mobilisation group (P < 0.05)
			Intensity of pain at 8 weeks	Significantly better in mobilisation group (P < 0.05)
McKinney LA et al 1989 UK	170 patients with acute whiplash injury Cervical collar (33) vs home mobilisation (66) vs physiotherapy (71)	PRCT	Severity of neck pain at 1 and 2 months	Mobilisation and physiotherapy significantly better than collar (P < 0.01)	Collar numbers small Rest group abandoned half way through trial
			Cervical movement at 1 and 2 months	Mobilisation and physiotherapy significantly better than collar (P < 0.01)
McKinney LA 1989 UK	128 of 170 patients with acute whiplash followed up at 2 years Physiotherapy vs advice on mobilisation vs initial period of rest	PRCT	Proportion of patients with symptoms at 2 years	Significantly lower in advice alone group	68% follow-up rate Rest group abandoned half way through trial All patients wore collars
			Proportion of patients with symptoms at 72 hours	No significant difference
Gennis P et al 1996 USA	196 of 250 patients with whiplash injury following automobile crashes Cervical collar vs no collar and unsupervised mobilisation	PRCT	Pain at 6 weeks	No significant difference	Short follow up period
Borchgrevink GE et al 1998 Norway	201 patients with neck sprain that resulted from a car accident Cervical collar vs unsupervised mobilisation	PRCT	Neck movement at 14 days and 24 weeks	Significantly better in mobilised group	Only 69% of patients completed the trial
			Neck pain at 14 days and 24 weeks	Significantly better in mobilised group
Rosenfeld M 2000 Sweden	97 patients with whiplash injury. Recruited from EDs and primary care. Active treatment involved the use of McKenzie principles. Patients randomised to either 1) active treatment, 2) active treatment after 14 days, 3) standard (rest with collar advised) treatment, 4) delayed standard (rest) treatment	PRCT	Mean number of sessions needed in active groups	3.95 sessions	Relatively small numbers means that although there are trends towards changes in ROM differences the study has insufficient power to demonstrate them. Collars were not worn by all standard group patients. Those in the treatment group required several interventions. Costs of this not examined
			Reduction in pain at 6 months	Greatest in early active group (30% more with no pain). Worst with early standard treatment (minimal change at 6 months) p<0.001
			Range of movemenrt	Most improvement in early active group (non significant)
			Active therapy: early vs late	Better if started early (p not given)
			Standard (rest) therapy: early vs late	Worst if started early
Crawford JR 2004 England	108 consecutive patients with soft tissue injury of the neck. Randomised to either early mobilisation with exercise or 3 weeks in a soft collar. Aged over 18 years. Analysis was by intention to treat.	PRCT	Requirment for additional physiotherapy	35% for mobilisation vs 45% for collar p=NS	Randomisation method based on hospital notes number (even or odd). Collar group had lower scores at baseline suggesting that they may have had a more serious baseline injury.
			Time off work	17.3 days for mobilisation vs. 34.4 for collar p=0.03
			Activities of daily living score (0-9) at baseline	7.01 for mobilisation vs. 5.92 for collar p=0.07
			Activities of daily living score (0-9) at 3 weeks	7.43 for mobilisation vs. 7.04 for collar p=0.43
			Activities of daily living score (0-9) at 12 weeks	7.08 for mobilisation vs. 7.38 for collar p=0.2
			Activities of daily living score (0-9) at 52 weeks	9.22 foe mobilisation vs. 9.33 for collar p=0.62
			Range of movement	No statistical or clinical differences found
Verhagen AP 2004 Not stated	Review of papers on the conservative treatment of whiplash. Extensive search of electronic databases and references of identified trials. Only RCTs included. Where data was unclear the authors reanalysed the original data, on occasions they came to different conclusions from the original authors.	Systematic review	Number of studies included	15 RCTs found	Search could be more extensive for a systematic review. Other interventions were also examined but are not included her as not relevant to the 3 part question. Non standard method of assessing quality of trials. Although the authors of this review are cautious in their interpretation, their data suggests a consistent finding that active interventions are probably better.
			Study quality	Only 3 studies were considered high quality
			Studies of active vs. passive interventions	High quality studies had conflicting results. Lower quality studies showed benefit to active treatments.
Rosenfeld M 2003 Sweden	97 patients with whipash injury. This is a 3 year follow up of patients from a previous study detailed in the BET table. Active treatments were McKenzie based. Standard treatment included rest and collar.	PRCT Long term follow up.	Proportion with no pain at 6 months	38% for early active, 17% for early rest, 23% for late active, 9% for late rest	91% followed up for 6 months. 75% followed up for 3 years. Size of study makes changes in other outcomes (e.g. range of movement) difficult to demonstrate.
			Proportion with no pain at 3 years	33% for early active, 33% for early rest, 44% for late active, 31% for late rest.
			Days sick leave at 3 years	11.2 for early active, 40.2 for early rest, 10 for late active, 20.5 for late rest
			Range of movement at 3 years	Statistical analysis suggests better of patients treated actively.

Comment(s)

There are numerous PRCTs and a systematic review in this area. The evidence appears to consistently suggest that active treatments are superior to rest or collar use. The systematic review is cautious in its conclusions as the quality of many of the studies (by their own unique score) was low. One difficulty is that in several studies long term findings are not that different, which arguably may well be the case. However, the active groups do appear to get better quicker.

Clinical Bottom Line

Patients with simple neck sprain (whiplash) should be advised on neck mobilisation and encouraged to commence as soon as possible. They should not be given cervical collars.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Mealy K, Brennan H, Fenelon GC. Early mobilization of acute whiplash injuries. Br Med J 1986;292:656-657.
2. McKinney LA, Dornan JO, Ryan M. The role of physiotherapy in the management of acute neck sprains following road-traffic accidents. Arch Emerg Med 1989;6:27-33.
3. McKinney LA. Early mobilisation and outcome in acute sprains of the neck. Br Med J 1989;299:1006-1008.
4. Gennis P, Miller L, Gallagher EJ et al. The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med 1996;3:568-73.
5. Borchgrevink GE, Kaasa A, McDonagh D et al. Acute treatment of whiplash neck sprain injuries. A randomized trial of treatment during the first 14 days after a car accident. Spine 1998;23:25-31.
6. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in Whiplash Associated Disorders: A comparison of two treatment protocols. Spine 2000;25:1782-1787
7. Crawford JR, Khan RJK, Varley GW Early management and outcome following soft tissue injuries of the neck - a randomised controlled trial. Injury 2004;35:891-895
8. Verhagen AP, Scholten-Peeters GGM, de Bie RA, Bierma-Zeinstra SMA Conservative treatments for whiplash The Cochrane database 2005; Edition 1.
9. Rosenfeld M, Seferiadis A, Carlsson J, Gunnarsson R. Active intervention in patients with whiplash associated disorders improves long-term prognosis. Spine 2003;28:2491-2498