To investigate the effectiveness of manual therapy in the treatment of whiplash, and to evaluate the methodological quality of the available studies.

The following sources were searched: MEDLINE from 1965 to March 1998, EMBASE from 1965 to March 1998, the Cochrane Library, PubMed (via the Internet), and Physiotherapy Index from 1990 to 1997. Search terms included 'clinical trial', 'effect study', 'cohort study', 'experiments', 'placebo', 'evaluation studies', 'whiplash', 'neck injury', 'cervical sprain', 'manipulation', '(physio)therapy', 'chiropractic', 'osteopathy', 'manual therapy' and 'passive mobilisation'. Reference lists of the identified studies were searched for additional references. Abstracts, unpublished studies, and studies published in languages other than English, Dutch or German, were not eligible for inclusion.

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were included.

Specific interventions included in the review

At least one of the treatment groups had to receive manual therapy. Manual therapy may consist of manipulation and/or passive mobilisation given alone or in combination with other conservative interventions. Studies in which manipulation was given with the aid of instruments, manipulations under sedation and/or manipulations that were not directed towards influence joint function, massage and neuromuscular therapies, were not included in the review. Studies with both short and long follow-up periods were eligible for inclusion. Interventions investigated in the included studies were mobilisation according to the Maitland method, and active and passive mobilisation. Control interventions included rest, neck braces, light mobilisation, pain-killers, advice for home mobilisation, verbal and written instruction for mobilisation, and use of neck brace and physical applications (transcutaneous electric nerve stimulation, ultrasonography). Cointerventions in the intervention groups included ice, warm and cold applications, homework exercises, UKG, hydrotherapy, traction, breathing training, neck school, psychological counselling, eye fixation exercises and muscle strengthening exercises.

Participants included in the review

Patients with acute or chronic complaints relating to the head-neck region that have been diagnosed as whiplash-associated disorders (WAD) grade one, two or three according to the definition of the Quebec Task Force (see Other Publications of Related Interest no.1). Complaints had to result from a road traffic accident.

Outcomes assessed in the review

Studies had to report at least one clinical outcome relating to pain, mobility, functional status, mental status, quality of life or a global measure of improvement. Outcomes reported in the included studies were pain, mobility, subjective evaluation of effectiveness of treatment, and physical health status.

How were decisions on the relevance of primary studies made?

The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.

The 'Delphi list' was used to assess study quality (see Other Publications of Related Interest no.2). Aspects of quality assessed were: method of randomisation, concealment of treatment allocation, baseline comparison of groups, specification of eligibility criteria, blinding, presentation of results, and whether an intention to treat analysis was conducted. Studies were assigned a score of 2 for each criteria fulfilled, 1 for each criteria not fulfilled, and 0 for each criteria for which it was unclear whether the criteria was fulfilled. The maximum possible score was 18. Studies scoring 0 to 5 were considered 'poor', 6 to 8 'average', 9 to 12 'acceptable', and 13 to 18 'good'. Included studies were blinded in relation to author, year, journal of publication and results, and were then assessed by two independent researchers. For points on which a consensus was not reached a third researcher made a decision.

The authors do not state how data were extracted for the review, or how many of the reviewers performed the data extraction. Data were extracted on number of patients, inclusion and exclusion criteria, interventions, outcomes, and points at which outcomes were assessed.

How were the studies combined?

The study results were discussed narratively.

How were differences between studies investigated?

Heterogeneity was not formally investigated although differences between the studies were discussed.

Four RCTs (n=471) were included.

The studies were of poor to acceptable quality with scores of 4, 5, 6 and 10. The duration of follow-up ranged from 8 weeks to 2 years. All studies looked at pain and mobilisation as outcome measures. In all studies, the difference in the interventions received by the treatment and control groups was not only manual therapy but also various other cointerventions. Thus, it is not possible to draw conclusions about the effectiveness of manual therapy in patients following whiplash trauma. Studies compared a combination of physical therapies and various cointerventions with treatments consisting of rest, neck braces, information and physical interventions. It is, therefore, not possible to report on the results of the effectiveness of mobilisations and/or manipulations for whiplash trauma.

There is no evidence to support the use of manual therapy for patients suffering whiplash trauma.

This was a good review of the area. The inclusion criteria were clearly specified and a thorough literature search was conducted. Since the review was limited to studies published in English, Dutch and German, some important studies may have been missed and the results may be subject to publication bias. Study quality was formally assessed and discussed extensively in the results. A narrative synthesis was appropriate in view of the heterogeneous nature of the studies, but since the authors discuss study details without providing any form of synthesis of results, this is the major limitation of the review. The authors' conclusions are supported by the results presented.

Practice: The authors did not state any implications for practice.

Research: The authors state that a methodologically-sound study of the effects of manual therapy is needed.

1. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining 'whiplash' and its management. Spine 1995;20:7S-73S. 2. Verhagen AP, De Vet HCW, De Bie RA, Kessels AG, Boers M, Bouter LM, Knipschild PG. The Delphi list: A criteria list for assessment of randomised clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998;51:1235-41.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.