The report of the Quebec Task Force on Whiplash-Associated Disorders scores a victory for spine science. It will serve as one milestone applying clinical epidemiology to clinical practice: the rules that distinguish truth from fashion.
This report is an indictment of the literature. From an inception pool of more than 10,000 publications, the Task Force found only 346 worth of consumption. This reflects how the literature has been polluted by the fashion to publish biographical papers—“what I do in my practice”—that offer no proof of either the reliability, validity, or true efficacy of that practice.
A parallel fashion has been to dismiss calls for controlled studies as, the ravings of obsessed academics: “research is for scientists, but I am a clinician.” Proper research is not an indulgence of academics; it is the basis of best practice and quality assurance. You cannot know that what you are doing is best for the patient unless the practice has been rigorously tested. Peer endorsement is no longer a substitute for scientific proof and cannot prevail over rigorous disproof.
The Task Force found the literature wanting. It could not even complete a table of the number of good studies per topic as it did for low back pain.10 On the topic of whiplash, there is no decent epidemiology, nothing written on diagnosis, and barely any treatment discussed works. Mobilization and manipulation seem to help for short periods of acute pain, but nothing helps for chronic pain.
Mercifully, it seems that the management of whiplash is not as riddled as the management of low back pain by medical excesses, such as expensive technologic investigations and controversial, major surgery. In stark contrast is the province of Quebec; the Task Force reports an extraordinary expense of some $1.5 million (Canadian dollars) for physiotherapy, when medical expenses were $230,000. Yet the report clearly finds no proven value for physiotherapy. A temporary moratorium on fees for physiotherapy would provide the funds needed to pursue the research called for by the report.
It is fascinating that the report from Canada (and Sweden) converges in time with similar initiatives elsewhere. The International Association for the Study of Pain has just published the second edition of its taxonomy, which streamlines the classification of spinal pain.9 That taxonomy rejects supposed diagnoses but recognizes “cervical spinal pain of unknown origin,” and “acceleration-deceleration injuries.” The Quebec Task Force extends the latter by offering four grades. However, none of these rubrics is a legitimate diagnosis. They are not based on the cause or even source of pain, but do serve as convenient, descriptors of presentations and are more honest than supposed diagnoses, such as spondylosis or the ubiquitous and ambiguous “softtissue injury.”
Unfortunately, the Quebec Task Force was not aware of other more modest initiatives instituted by the Motor Accidents Authority of New South Wales. However, this convergence reflects a worldwide recognition of the serious social, economic, and medical problem of whiplash.
The Quebec Task Force provides a cogent and exhaustive summary of the state of the art as of September 1993. What is not reflected, though expected, is the rapid progress that has been made since then. Whereas the Quebec study emphasized, in its findings and in its recommendations, the epidemiology, prognosis, clinical features, and treatment of whiplash, the Australian thrust has been on its pathology, pathophysiology, and diagnosis.3 This literature appeared too late for inclusion in the Quebec report. Experimental studies and postmortem studies have yet to prove the “lesion” of whiplash, but they have set a spectrum of possibilities.3 The likely lesions are tears to muscles, rim lesions of the discs, and occult fractures or injuries to the zygapophysial joints.6,11 No clinical studies have addressed the validity of diagnostic or epidemiologic factors associated with muscle “lesions” and disc “lesions,” but painful zygapophysial joints have been studied.
Pain is not morphologic; it cannot be seen on radiographs, computed tomography, or magnetic resonance imaging. Pain can be pursued using diagnostic blocks. In this regard, the Australia studies have established the face validity,1 construct validity,2 and use of controlled, diagnostic blocks of the cervical zygapophysial joints. Under double-blind, controlled conditions, it has been shown that zygapophysial joint pain is the single most common basis for chronic neck pain after whiplash,5 and that at least 27% of the headaches after whiplash can be traced to the C2-C3 zygapophysial joints.7 Although treatment with intra-articular steroids is not unreasonable,4 results with percutaneous radiofrequency neurotomy have been promising but capricious.8 Controlled studies are nearing completion.
The Quebec Task Force emphasizes that whiplash is essentially a benign condition with the vast majority of patients recovering, but it is the refractory minority that accounts for an inordinate proportion of the costs. With respect to these patients, the state of the art may not be as bleak as portrayed by the Task Force. Spine science is moving fast. Some of the research that the Task Force called for is already being done and has been done. We congratulate the Task Force on this much needed effort, and we hope it will guide us in the appropriate direction to diagnose, treat, and research this most costly clinical problem.
University of Newcastle Newcastle, Australia
1. Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophysial joint pain. Regional Anaesthesia 1993;18:343-50.
2. Barnsley L, Lord S, Bogduk N. Comparative anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain 1993;55:99-106.
3. Barnsley L, Lord S, Bogduk N. Clinical review: Whiplash injuries. Pain 1994;59:292-307.
4. Barnsley L, Lord SM, Wallis BJ, Bogduk N. Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. N Engl J Med 1994;330:1047-50.
5. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995;20:20-5.
6. Jönsson H, Bring G, Rauschning W, Sahlstedt B. Hidden cervical spine injuries in traffic accident victims with skull fractures. J Spin Dis 1991;4:251-63.
7. Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital headache: A perspective study. J Neurol Neurosurg Psychiatry 1994;57:1187-90.
8. Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment of neck pain: A caution. Neurosurgery 1995; in press.
9. Merckey H, Bogduk N (eds). Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definition of Pain Terms, 2nd ed. Seattle: IASP Press, 1994.
10. Quebec Task Force on Spinal Disorders. Scientific approach to the assessment and management of activity-related spinal disorders. Spine 1987;12:S1-S58.
11. Taylor JR, Tworney LT. Acute injuries to cervical joints: An autopsy study of neck sprain. Spine 1993;18:1115-22.