Richtlijn Whiplash Eng - ifompt

KNGF-guidelines for physical therapy in patients with whiplashClinical practice guidelines for physical therapy inpatients with whiplash-associated disordersBekkering GE, I,II Hendriks HJM, I,III,IV Lanser K, V Oostendorp RAB, I,VI,VII,VIII,IX Scholten-Peeters GGM, I,VI,VIIVerhagen AP, X van der Windt DAWM. IIIntroductionThese guidelines describe the diagnostic andtherapeutic processes involved in the physicaltherapy of patients suffering the harmfulconsequences of whiplash injury to the neck.Principle of these guidelines is that whiplash traumainvolves minor soft tissue damage that may lead to anumber of complaints, which are referred to as‘whiplash-associated disorders’. These complaintscan be described in terms of impairments (such aspain or a decreased range of motion of the neck),disabilities (for example, in performing normal dailyactivities) and problems with social participation (forexample, problems in returning to work or reducedsocial contact). In these guidelines, a bio-psychosocialapproach to the consequences of whiplash traumahas been adopted. The pathophysiology of whiplashinjury and the choices made in arriving at guidelinerecommendations are described in the ‘Review of theevidence’, the second part of these guidelines. Thekey concepts used are explained in an appendedglossary.A bio-psychosocial approach has been adopted as thestarting point for the physical therapy of patientssuffering the consequences of whiplash injury.Definition of whiplashWhiplash is an acceleration-deceleration mechanismof energy transfer to the neck. It may result from rearimpactor side-impact collisions in a motor vehicle,and can also occur during diving, for example. TheTable 1. Classification of the grades of severity of whiplash-associated disorders.*Grade Description0 no complaints, no physical signs1 pain, stiffness and tenderness in the neck, but no physical signs2 neck complaints and other musculoskeletal complaints (e.g., a decreased range of motion andtender spots)3 neck complaints and neurological signs (e.g., decreased or absent deep tendon reflexes, weakness,and sensory deficits)4 neck complaints and fractures or dislocations* Symptoms and disorders that can be manifested in all grades of severity include deafness, dizziness,tinnitus, headache, memory loss, dysphagia and temporomandibular pain.I. Dutch Institute of Allied Health Professions (NPi), Amersfoort, the NetherlandsII. Institute for Research in Extramural Medicine, Faculty of Medicine, Vrije Universiteit Medical Center, Amsterdam, the NetherlandsIII. Department of Epidemiology, Maastricht University, Maastricht, the NetherlandsIV. Physical therapy and manual therapy practice ‘The Klepperheide’, Druten, the NetherlandsV. Integral Neck and Back Center, Hardinxveld-Giessendam, the NetherlandsVI. Faculty of Medicine and Pharmacology, Department of Manual Therapy, Vrije Universiteit Brussel, Brussels, BelgiumVII. Spine and Rehabilitation Center, Uden, the NetherlandsVIII. Physical therapy and manual therapy practice, Heeswijk-Dinther, the NetherlandsIX. Center for Quality-of-Care Research, University Medical Center, Catholic University of Nijmegen, the NetherlandsX. Department of General Practice, Erasmus Medical Center Rotterdam, the NetherlandsV-09/2003/US1

KNGF-guidelines for physical therapy in patients with whiplashimpact may result in injury to bony or soft tissue (i.e.,whiplash injury), which in turn may lead to a varietyof clinical manifestations. Frequently occurringsymptoms are neck pain, decreased mobility of thecervical spine, headache, and dizziness. The clinicalsymptoms, which are known as whiplash-associateddisorders, can be classified into five grades of severity(Table 1). These guidelines concentrate on patientswith grade-1 and 2 whiplash-associated disorders.Patients with neurological signs, fractures ordislocations are not covered by these.In addition, the time that has passed since the injurycan be divided into six phases: less than four days;four days to three weeks; three to six weeks; six weeksto three months; three months to six months, andmore than six months. In these guidelines, the timethat has passed since the injury is related to theconsequences of whiplash.EpidemiologyEpidemiological data on the incidence of whiplashare mainly derived from insurance claim numbers.Therefore, the reported annual incidence of whiplashvaries widely between countries and continents:figures vary from 16 per 100,000 inhabitants eachyear in New Zealand to 70 per 100,000 inhabitantseach year in Quebec, Canada. In the Netherlands, thenumber of new patients who have experiencedwhiplash is estimated to be 94–188 per 100,000inhabitants each year. These figures are much higherthan international estimates because they are derivedfrom accident statistics. There are no Dutch data onthe prevalence of specific symptoms after whiplash.PrognosisThere is no consensus in the literature on theprognosis of the consequences of whiplash. Theprevalence of long-term complaints (i.e., from sixmonths to two years) varies from 19–60%. ACanadian research group, the Quebec Task Force onwhiplash-associated disorders (QTF-WAD), reported thatthe prognosis is favorable: around 85% of patientsreturn to work within six months after the whiplashinjury. Recently, this conclusion has been criticizedbecause the severity and duration of the complaintsmay have been underestimated.Normal and delayed recoveryA distinction is made between patients who undergonormal recovery and those who undergo delayedrecovery after whiplash injury. Normal recovery refersto the ‘average’ or ‘expected’ course of recovery fromthe consequences of whiplash. Normally, over timethe patient’s functions improve, the patient’s levels ofactivity and participation increase, and the patient’spain level declines. Moreover, there is someinterrelationship between impairments, disabilitiesand participation problems. When recovery isdelayed, it may be that the patient’s functions donot improve or the patient’s levels of activity andparticipation do not increase or the patient’s painlevel does not decline with time. Moreover, theinterrelationship between impairments, disabilitiesand participation problems is less obvious. In theworking group’s view, recovery can be said to bedelayed if a patient suffering the consequences ofwhiplash shows no progress in terms of levels ofactivity and participation within four weeks.Table 2. Prognostic factors associated with delayed recovery after whiplash.Whiplash-related factors:• decreased mobility of the neck immediately after injury;• pre-existing head trauma;• female gender;• volder age.Factors related to chronic pain:• coping strategy;*• psychosocial factors (e.g., passive coping, fear or job dissatisfaction).* can be influenced by physical therapy2V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashWith normal recovery, activity and participationlevels increase over time. This is not the case withdelayed recovery.Prognostic factorsA number of factors are associated with delayedrecovery after whiplash injury (Table 2). The first fourfactors listed in the table are related to whiplash; thelast two factors concern chronic pain in general.Coping strategyDuring recovery, patients may cope with theircomplaints either adequately or inadequately. Copingis connected with the extent to which a person is ableto adjust his* load (i.e., what he wishes to do) to hisload-bearing capacity (i.e., what he can do). Loadbearingcapacity depends on the patient and is, amongother things, determined by the time that has passedsince the injury, which is related to the physiologicalrecovery phase, and by psychosocial factors.People who continue to perform their activities orwork in appropriate ways have adequate copingstrategies. When complaints persist, the adoption ofstrategies such as seeking distraction from pain oraiming for an active life style indicate adequatecoping. People who, on the other hand, restrict theirmovements because of their complaints, who persistin avoiding certain activities, or who rest a lot torelieve pain have inadequate coping strategies.The significance attached to pain and the level ofcontrol experienced are important in respect tocoping. The significance a patient attaches to hiscomplaint very much determines the complaint’semotional impact, which can vary from being “notthreatening at all” to being “highly threatening”. Themore a patient feels threatened by his complaints, thehigher the likelihood that he will cope inadequately.Patients experience a high level of control when theyunderstand the health problem and have theconfidence to able to influence their complaintsthemselves. In addition, social factors, such as thepatient’s interaction with his environment, caninfluence coping strategy.Role of the physical therapistThe general objectives of physical therapy are toenable the patient suffering the consequences ofwhiplash to return to normal, or desired, levels ofactivity and participation, and to prevent thedevelopment of chronic complaints.In the first three weeks after whiplash, the physicaltherapist should observe the patient and should takeactions that encourage recovery from the injury tofollow a natural course. From three to six weeks afterwhiplash, the physical therapist should, if necessary,try to modify the patient’s coping strategy usingbehavior-oriented principles that focus on thepatient’s functioning. Here, the physical therapist’sattitude can have an influence on recovery. If toomuch attention is paid to pain and not enough toencouraging activity, recovery can be negativelyaffected.The objectives of physical therapy are to enable thepatient to return to normal, or desired, levels ofactivity and participation, and to prevent thedevelopment of chronic complaints.Interdisciplinary cooperationIn the Netherlands, there are no guidelines forprimary care physicians or medical specialists, whichdescribe the treatment of patients suffering theconsequences of whiplash. The Dutch WhiplashAssociation has published an advisory note as a firststep in achieving a clear policy on the initial care ofpatients with whiplash injuries. More details aregiven in the review of the evidence. To help optimizecooperation and communication between primarycare physicians and physical therapists, speciallydeveloped guiding principles could be used. Thesecover indication setting, letters of referral, consultation,contact during treatment, and writing reports.DiagnosisThe objective of the physical therapy diagnosticprocess is to assess the severity and nature of thehealth problem affecting the individual patient andthe extent to which it can be influenced. The* The combination ‘his/her’ and ‘he/she’ have been avoided in these guiselines to facilitate readability. The terms ‘his’ and ‘he’ should beunderstood to apply to both sexes.V-09/2003/US3

KNGF-guidelines for physical therapy in patients with whiplashpatient’s needs are of primary concern. The physicaltherapist assesses how the condition has progressedand relates this to the time that has passed since theinjury. He also assesses the patient’s coping strategyand knowledge about his condition.ReferralCarrying out treatment in accordance with theseguidelines requires referral from a primary carephysician or medical specialist. The referraldocumentation must describe the reasons for referral.If it does not, the physical therapist must contact thereferring physician. Referral data should includedetails of: the whiplash-associated disorder grade ofseverity; the patient’s previous history, including, inparticular, information on pre-existent complaints,known deviations from the usual situation, otherdisorders, and medication use; and relevantpsychosocial factors.History-takingDuring history-taking, the physical therapist shouldobtain information about the patient’s functions andlevels of activity and participation, and about factorsthat either promote or inhibit recovery. The physicaltherapist should also ask about demands made on thepatient by his normal daily activities and by hisworking situation to gain an impression of thepatient’s load in relation to his load-bearing capacity(Table 3).Assessment tools can be used to evaluate objectivelythe observations made and the effects ofinterventions. The working group advises use of thefollowing tools in patients suffering the consequencesof whiplash:• Visual analogue scales – used to map the intensityof the patient’s ‘most important complaints’. It isrecommended that visual analogue scales are usedat set time periods;• Neck disability index – used to map the patient’sfunctioning systematically;• Daily diary – used to record the patient’s activities.For example, in practice, the patient keeps a dailydiary for one week that contains details of theactivities he undertakes, how often and for howlong he undertakes them, and whether theseactivities result in a decrease, no change or anincrease in the level of complaints. Also includedare details of any actions taken when the level ofcomplaints increases, such as pain medication use,resting, or seeking distraction.Table 3. Main points of history-taking in patients suffering the consequences of whiplash.Details of current complaints and patient’s needsAccident-related data:- details of the situation before the whiplash, including data on any pre-existing or similar complaints,and on the patient’s activities and level of participation;- accident-specific information.Patient’s progress over time:- data on impairments, disabilities and participation problems, including details of their severity andnature;- data on previous diagnoses, treatment and the results of treatment;- details of any other earlier information and who provided it.Coping strategy:- What meaning does the patient give to his complaints?- Does the patient have control over his complaints?Status praesens:- systematically ask about different functions, activities and forms of participation;- Is the (bio-psychosocial) load in proportion to the patient’s load-bearing capacity?- present treatment, including details of medication use and other treatments;- assessment of patient’s information needs.4V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashExaminationObservation and palpationThe physical therapist observes and examines thepatient’s body posture and motion, paying specialattention to the spinal column. The main points areto look for the presence of a list and to observe neckmuscle tonus.Physical examinationDuring physical examination, the physical therapistassesses the patient’s functions and activities,preferably by using active methods of examination.At a minimum, the following functions should beexamined:• the functioning of joints in the cervical spinalcolumn and shoulder region (mobility and rangeof motion should be assessed, and whethersymptoms can be provoked);• muscular function (muscular stability of cervicalspinal column);• balance (by using a tightrope walker’s gait orstanding on one leg).Additional examination of the patient’s functionsand activities may be carried out depending on thepatient’s needs and whether he has any problemsperforming normal daily activities.If the physical therapist suspects neurologicaldamage, he should carry out a neurologicalexamination. This should include tests of sensibility,muscle strength and tendon reflexes in the upperextremities. If a neurological deficit is present, thereferring physician should be consulted or the patientshould be referred back to him.AnalysisDuring analysis, answers must be obtained to thefollowing questions:• What are the consequences of whiplash, in termsof impairments, disabilities* and participationproblems**?• Which phase is the patient in (in terms of thetime that has elapsed since the injury)?• Is recovery normal or delayed?• Is local or systemic load balanced with local orsystemic load-bearing capacity?• At present, which factors inhibit recovery(Table 2)?:- Is the patient coping adequately?- Are there any other inhibitory factors?• Can impairments, disabilities, participationproblems and factors inhibiting recovery beinfluenced by physical therapy?After analysis it should be clear whether physicaltherapy is indicated and whether it is possible to treatthe patient according to the guideline. The physicaltherapist then formulates a treatment plan togetherwith the patient. If the physical therapist suspectsthat certain complaints, such as dizziness, or certainfactors, such as the patient’s coping strategy, can onlybe influenced to a limited extent by physical therapy,he should contact the referring physician.The treatment plan is determined by the patient’sload-bearing capacity, the relevant impairments,disabilities and participation problems, and how thepatient is recovering from the consequences ofwhiplash over time.Treatment planThe most important physical therapy interventionsfor patients suffering the consequences of whiplashare counseling and exercise therapy. Counselinginvolves providing support, information and advice.The physical therapist teaches the patient how tocope with his complaints independently, how toinfluence his complaints, and how to act if there is areversal in or an aggravation of the condition. Theeffect of other interventions, including massage,traction, mobilization, ultrasound therapy, shortwave therapy, laser therapy and electrotherapy, hasnot been investigated or their efficacy has not beendemonstrated in this group of patients. Therefore, useof these interventions is not covered by theseguidelines.The physical therapy of patients whose recovery isnormal focuses on disabilities (in, for example,* In terms of the ICF (International Classification of Functioning, Disability and Health): Activity limitations.** In terms of the ICF (International Classification of Functioning, Disability and Health): Participations restrictionsV-09/2003/US 5

KNGF-guidelines for physical therapy in patients with whiplashlifting, carrying, or maintaining a sitting position)and the impairments that cause these disabilities(such as, decreased mobility or decreased muscularstability). A central element of treatment in patientswith delayed recovery is, if necessary, influencingcoping strategy. In addition, treatment also includesphysiological training and providing appropriateexercise therapy.Phase 1 (up to four days after the injury)In the first three days after the whiplash injury, localreactions to tissue damage occur. The most importantsymptom is pain. If the pain intensity is high, thepossible use of pain medications should be discussedwith the primary care physician. Treatment aims toreduce the load on the patient, thereby enablingtissues to recover.Treatment goals in each phaseIn phase 1 (up to four days after whiplash), treatmentfocuses on load reduction. In phase 2 (four days tothree weeks), the patient’s functions are improvedand the load is gradually increased. This policy iscontinued into phase 3 (three to six weeks) and phase4 (six weeks to three months). If recovery is delayed,treatment focuses on factors that maintain thecomplaints. Central concerns are the patient’s copingstrategy and ensuring that the patient’s levels ofactivity and participation are gradually increased bymeans of an exercise program (Table 4).TherapyThe therapeutic process is based on the individualtreatment plan formulated by the physical therapisttogether with the patient. It is elaborated inaccordance with different phases mentioned above,which start at the time of the accident. These phaseshave to be seen as a series of gradual divisions in theprocess. The use of collars, including soft collars, isnot recommended. If a patient is wearing a (soft)collar at the time of referral, the physical therapistwill arrange for its use to be reduced afterconsultation with the referring physician.Treatment goals: reduce pain, and increase thepatient’s knowledge about and insight into hiscondition.Interventions: counseling, including the provision ofinformation and advice.Providing information and adviceThe physical therapist should inform the patientabout the nature of the injury and its natural courseof recovery and give advice on how to reduce theload on the patient. To aid functional recovery, thephysical therapist should advise the patient to movein a well-balanced way.Phase 2 (four days to three weeks after the injury)In this phase, the patient’s functions are improvedand the load on the patient can be slowly increased.It is important that he gradually increases his levels ofactivity and participation to prevent the developmentof a fear of movement or of an imbalance betweenload and load-bearing capacity.Treatment goals: increase the patient’s knowledgeabout and insight into his condition, and improvefunctions.Table 4. Physical therapy subgoals in the different phases of treatment, divided according to the time that haselapsed since the injury.Subgoals Phase 1 Phase 2 Phase 3 Phases 4, 5 and 6(< 4 days) (4–21 days) (3–6 weeks) (> 6 weeks)Reducing painXIncreasing knowledge of andinsight into the condition X X X XImproving functions X XIncreasing levels of activity and participation X XPromoting an adequate coping strategy X X6V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashTable 5: Steps in the process of changing behavior, including movement behavior.1. Being open to information about the need to change behavior.2. Being able to understand and recall the information received.3. Wanting to change behavior.4. Being able to change behavior.5. Demonstrating the new behavior (doing).6. Keeping on doing the new behavior over the long term.Interventions: counseling, including the provision ofinformation and advice, and giving exercise therapy.Providing information and adviceThe physical therapist should inform the patientabout the nature of the injury and the expectedcourse of recovery and explain that moving in a wellbalancedway is not harmful but instead benefitsrecovery, even if it causes a reaction, such as pain.The patient learns to cope with his symptoms andlearns how to increase his level of activity, whilebearing in mind: the balance between load and loadbearingcapacity; the need to divide time into periodsof rest and periods of activity; and the instructions onposture he has received.It is important that the patient learns to increase hisactivity level in a manner that is neither too slow nortoo fast. If the load on the patient is too low, thephysical therapist should explain that it is importantto increase activity level. If the load on the patient istoo high, he should be instructed to slow down. If itis desirable, the patient’s load could be low at thebeginning of the recovery period, after which it couldbe increased gradually to the highest level feasible.The physical therapist should regularly evaluatewhether the patient understands the informationprovided and whether he can apply the advicereceived in his own environment. In conjunctionwith the patient, the physical therapist should seeksolutions to any problems the patient experiences infollowing advice.When recovery is normal, the patient will himselfincrease his levels of activity and participation.Consequently, behavioral change is unnecessary. Thephysical therapist should encourage the healthymovement behavior and help the patient toconsolidate it. These activities correspond to steps 5and 6 in the process of changing behavior (i.e., doing,and keeping on doing) described in Table 5.When recovery is abnormal or when the patient hasan inadequate coping strategy, the physical therapistmust try to change the patient’s behavior, forexample, by helping him recognize his limitations interms of the tempo, duration, number and nature ofhis activities and by helping him increase his loadgradually.For successful behavioral change, it is essential thatthe patient trusts his own abilities (i.e., experiencesself-efficacy) and that the advantages of the changeoutweigh the disadvantages. This means that thephysical therapist, together with the patient, shouldset achievable goals and that the advantages anddisadvantages of the behavioral change should bediscussed. Furthermore, it is important that thetherapist provides information systematically andgradually in a way that takes into account thepatient’s knowledge and perceptions. The form andcontent of the information has to match the phase ofbehavioral change that the patient is in. Followingthe steps listed in Table 5 can be helpful in bringingabout behavioral change. Note that it is only whenone step has been completed that the next step canbe taken.Exercise therapyThe objective of exercise therapy is to improveselected functions and activities. The patient may alsoexperience positive behavioral changes.Phase 3 (three to six weeks after the injury)In this phase, the patient’s functions are improvedV-09/2003/US7

KNGF-guidelines for physical therapy in patients with whiplashand the load on the patient is increased. Pain nolonger plays a central role. The aim is to increase thepatient’s activities gradually and to help the patientreturn to as normal a level of participation aspossible. If necessary, the physical therapist shouldencourage the patient to adopt a more adequatecoping strategy.Treatment goals: increase the patient’s knowledgeabout and insight into his condition, improvefunctions, increase levels of activity andparticipation, and encourage an adequate copingstrategy.Interventions: counseling, including the provision ofinformation and advice, and giving exercise therapy.Providing information and adviceThe physical therapist should encourage patientswhose recovery is normal to carry out their usualactivities and to participate socially as much aspossible. The physical therapist and the patientshould discusses how best to cope with the conditionand how to increase activity levels, while taking intoaccount advice given in the section on providinginformation and advice in phase 2. In patients whoserecovery is delayed or who have an inadequatecoping strategy, the physical therapist should attemptto change the patient’s movement behavior, asdetailed in phase 2.Exercise therapyPatients who have a fear of movement or who avoidmoving should be exposed to a gradual safe increasein their loads To achieve this, the physical therapistshould select, together with the patient, activitiesthat the patient is afraid of, and these should bepracticed. The objective is for the patient to have apositive experience of carrying out the selectedactions. The size of the steps taken depend on thepatient’s starting level (i.e., the baselinemeasurement), the ultimate goals that have beenformulated for the individual patient, and thepatient’s progress. Furthermore, practical functionsand activities are exercised. In improving functionssuch as muscle strength, it is useful to followphysiological exercise principles.Phase 4 (six weeks to three months after theinjury)If there is no progress in terms of levels of activityand participation in this period, recovery is delayed.Depending on the patient’s load-bearing capacity,therapy should begin with either a recovery period,in which the load is lowered, or with a period ofincreased load. The patient’s coping strategy is ofcentral important in treatment.Treatment goals: increase the patient’s knowledgeabout and insight into his condition, improvefunctions, increase levels of activity andparticipation, and encourage an adequate copingstrategy.Interventions: counseling, including the provision ofinformation and advice, and giving exercise therapy.Providing information and adviceThe physical therapist tries to change the patient’smovement behavior or encourages the patient tocontinue with the new movement behavior byproviding information and advice, as detailed in thesection on providing information and advice in phase2. This involves encouraging an increase in the levelsof activity and participation, and controlling orinfluencing, if possible, the impact inhibitory factorshave on the patient’s level of participation. Inparticular, special attention must be paid toparticipation in the workplace during this phase. It isimportant to assess the influence of inhibitory factorsin the patient’s work environment so that the patientcan anticipate their effects and so that the physicaltherapist can pay attention to them during treatment.Preferably, an occupational physician should beconsulted.Exercise therapyExercise therapy consists mainly of exercising andtime-expanding of relevant activities. In the exerciseprogram, exercise duration is gradually increasedwhile the balance between load and load-bearingcapacity is monitored. The training of specificfunctions is clearly associated with improvements inlevels of activity and participation.8V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashPhases 5 and 6 (more than three months after theinjury)The longer the impairments, disabilities andparticipation problems persist, the smaller the chanceof full recovery to the health status before theaccident. In these phases, treatment is the same as inphase 4.EvaluationThe physical therapist should regularly evaluate theresults of treatment during therapy by monitoringthe course of the complaints, the patient’s copingstrategy, and his levels of activity and participation.The measuring instruments mentioned in thedescription of the diagnostic process can be used forthis purpose. The treatment plan can be modified onthe basis of these evaluation, if necessary. If treatmentis having no effect, the physical therapist shouldcontact the referring physician or refer the patientback to him. Treatment ends when the treatmentgoals have been achieved or when further treatmentis not expected to produce positive results.Final evaluation, conclusion andreportingThe referring physician should be informed at theend of the treatment, and possibly during treatment,about individual treatment goals, the treatmentprocess and treatment results. Information on how todo this is given in guidelines issued by the RoyalDutch Society for Physical Therapy (KNGF), entitled“Communicating with and reporting back to generalpractitioners”. Written reports should conform toKNGF guidelines, entitled “Physical therapeuticdocumentation and reporting.”Treatment ends when the treatment goals have beenachieved or when further treatment is not expectedto produce positive results.V-09/2003/US 9

KNGF-guidelines for physical therapy in patients with whiplashReview of the evidenceGeneral introductionThe guidelines on whiplash-associated disordersissued by the Royal Dutch Society for PhysicalTherapy (KNGF) provide a guide to the physicaltherapy of adult patients suffering from whiplashassociatedcomplaints, which are described in termsof impairments, disabilities and participationproblems. The guidelines describe a methodicalapproach to the diagnostic and therapeutic processesinvolved.DefinitionKNGF guidelines are defined as “a systematicdevelopment from a centrally formulated guide,which has been developed by professionals, thatfocuses on the context in which the methodicalphysical therapy of certain health problems is appliedand that takes into account the organization of theprofession”. 1,2Objective of the KNGF guidelines on whiplashassociateddisordersThe objective of the guidelines is to describe theoptimal physical therapy, in terms of effectivenessand efficiency, for patients with complaints or healthproblems caused by whiplash as derived from currentscientific research and from professional and moregeneral knowledge. The care provided should lead tofull, or desired, levels of activity and participationand should help prevent the development of chroniccomplaints and recurrences.expertise which are necessary to insure treatmentaccording to the guidelines.Main clinical questionsThe working group that formulated these guidelinesset out to answer the following questions:• What is the natural course of recovery fromwhiplash injury and which prognostic factorspredict the course of recovery?• Which factors can be influenced by physicaltherapy?• What is the objective of physical therapy inpatients suffering the consequences of whiplash?• Which parts of the physical therapy diagnosticprocess are valid, reliable and useful in dailypractice?• Which forms of treatment and preventionproduce clinically significant results?The monodisciplinary working groupIn October 1998, a monodisciplinary working groupof professionals was formed to find answers to theseclinical questions. In forming the working group, anattempt was made to achieve a balance betweenprofessionals with experience in the area of concernand those with an academic background. Allmembers of the working group stated that they hadno conflicts of interest in participating in thedevelopment of these guidelines. Guidelinedevelopment took place from October 1998 throughDecember 2000.In addition to the above-mentioned guideline goals,KNGF guidelines are explicitly designed:• to adapt the care provided to take account ofcurrent scientific research and to improve thequality and uniformity of care;• to define and provide some insight into the tasksand responsibilities of professional groups and tostimulate cooperation; and• to aid the physical therapist’s decision-makingprocess with regard to deciding whether to treatand to assist in the use of diagnostic andtherapeutic interventions.To make use of the guidelines recommendations areformulated with regard to professionalism andMonodisciplinary working group proceduresThe guidelines were developed in accordance withconcepts outlined in a document entitled “A methodfor the development and implementation of clinicalguidelines”. 1–4 This document includes practicalrecommendations on the strategies that should beused for collecting scientific literature. Below, in thisreview of the evidence for these guidelines, details aregiven of the specific terms used in literature searches,the sources searched, the publication period of thesearched literature, and the criteria used to selectrelevant literature.Although members of the working group selected and10V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashgraded the scientific evidence either individually orin small subgroups, the results were presented to anddiscussed by the whole working group. Thereafter, afinal summary of the scientific evidence, whichincluded details of the amount of evidence available,was made. In addition to scientific evidence, otherimportant factors were taken into account in makingrecommendations, such as the achievement of ageneral consensus, cost-effectiveness, the availabilityof resources, the availability of the necessary expertiseand educational facilities, organizational matters, andthe desire for consistency with othermonodisciplinary and multidisciplinary guidelines. Ifno scientific evidence was available, guidelinerecommendations were based on the consensusreached within the working group or by a group ofprofessionals.Once the draft monodisciplinary guidelines werecompleted, they were sent to a secondary workinggroup comprising external professionals or membersof professional organizations, or both, for commentson the recommendations and to ensure that therewas agreement with the views of other professionalorganizations and with any other existingmonodisciplinary or multidisciplinary guidelines. Inaddition, the wishes and preferences of patients weretaken into account through consultations with arepresentative of the Dutch Whiplash Foundation.Validation by intended usersBefore they were published and distributed, theguidelines were systematically reviewed and testedby intended users for the purpose of validation. Thedraft KNGF guidelines on whiplash-associateddisorders were presented for assessment to a group of50 physical therapists who had the required skillsand who were working in different settings. Physicaltherapists’ comments and criticisms were recordedand discussed by the working group. If possible ordesirable, they were taken into account in the finalversion of the guidelines. The finalrecommendations on practice, then, are derivedfrom the available evidence and take into accountthe other above-mentioned factors and the results ofthe guideline evaluation carried out by intendedusers.Composition and implementation of theguidelinesThe guidelines comprise three parts: the practiceguidelines themselves, a schematic summary of themost important points in the guidelines, and a reviewof the evidence. Each part can be read individually.After the guidelines were published and distributed toKNGF members, a scientific article containing the mostimportant guideline recommendations waspublished. 5 In addition, a professional developmentmodule was produced and published to stimulate useof the guidelines in daily practice. 6 A similar modulewas also developed as a short course for smallgroups. 7 The emphasis is on practical skills and theintention is to support the implementation of theKNGF guidelines on whiplash-associated disorders. Theguidelines should be implemented in accordancewith a standard method of implementation. 1–4,8Introduction to these guidelinesThis review of the evidence concerns the KNGFguidelines on whiplash-associated disorders. Theseguidelines are intended for the treatment of patientswho are suffering the negative consequences ofwhiplash. A bio-psychosocial approach has beenadopted as the starting point for physical therapy. Inthese guidelines, the expression “the consequences ofwhiplash” is used to cover, in a neutral way,impairments, disabilities and participation problems.Because very few controlled studies on whiplash havebeen carried out so far, guideline recommendationshave been based on scientific literature on thetreatment of chronic benign pain as well as onscientific literature on the treatment of whiplash. Animportant similarity between chronic benign painand the long-term consequences of whiplash is that,in both, bio-psychosocial factors can causecomplaints to persist. In addition, in both groups ofpatients, objective impairments in body structurescan often not be detected. 9Impairments, disabilities and participationproblemsThe physical therapist can describe the patient’scomplaints and perception of his health problems(i.e., the consequences of whiplash) in terms ofimpairments, disabilities and participation problems.Impairments are manifestations of a disorder thatV-09/2003/US 11

KNGF-guidelines for physical therapy in patients with whiplashinvolve body structure or body functions (e.g.physiological or psychological functions). Examplesare dizziness, pain or impaired sensibility. Disabilitiesare problems performing activities such as bending,reaching or walking. Participation problems areproblems with participation in social life, such asproblems participating in work or family life. Theseconcepts are derived from a provisional version of theInternational Classification of Impairments,Disabilities and Handicaps (ICIDH-2), 10 which has nowevolved into the International Classification ofFunctioning, Disability and Health (ICF). The aim ofusing these concepts is to increase the uniformity ofthe language used in physical therapy. In the ICIDH,the terms functioning and dysfunction are used asumbrella concepts to cover impairments, disabilitiesand participation problems. In the guidelines issuedby the Dutch College of General Practitioners (NHG),the term dysfunction is defined as “a level of dailyfunctioning that is not able to fulfill the patient’sdemands or the demands made on the patient by hisenvironment in terms of the performance of normaldaily activities and work”. 11Bio-psychosocial modelWithin the physical therapy profession, it isbecoming increasingly important to view pain interms of the integrated effect of physical,psychological and environmental factors. Thesefactors interact continuously with one another. 12The physical factors that initially cause pain canbecome less important over time, even though thedisabilities experienced by the patient in his daily lifeeither stay the same or worsen. This phenomenon isdue to psychosocial factors.Guidelines target groupThese guidelines are intended for all physicaltherapists who individually treat patients sufferingthe consequences of whiplash. The physical therapyprinciples described herein can, however, also be usedin treatment provided in a multidisciplinary settingor in a group. The physical therapist requires specificknowledge and skills to treat patients suffering theconsequences of whiplash in a group setting. TheKNGF has developed quality criteria that apply togroup treatment. These criteria concern the methodsused, the physical therapist’s approach, and theprofessional performance. 13In order to use these guidelines appropriately, thephysical therapist must know about the naturalcourse of recovery from the consequences ofwhiplash and the significance of prognostic factors.The physical therapist can use this knowledge tojudge whether and to what extent the patient’scomplaints could be influenced positively.Furthermore, the physical therapist must haveexperience in providing information in a methodicalway so that he can influence the patient’s behavior.He must also be familiar with behavior-orientedprinciples and how they apply to the patient’sfunctioning.PathophysiologyMechanismIn contrast to the hyperextension hypothesis used asan explanation for whiplash injury in the past,Panjabi et al. 14 observed, in an in vitro experiment onwhiplash injury, that the cervical spinal columnundergoes a two-phase reaction during whiplash. Inthe first phase, the spinal column forms as S shapeinvolving flexion of the upper cervical spinal columnand hyperextension of the lower cervical spinalcolumn. In the second phase, extension occurs at alllevels of the spinal column. On the basis of theirobservations, the authors concluded that whiplashinjury occurs in the first phase, before the neck isfully extended. Thereafter, the lower cervical spinalcolumn is injured during hyperextension. At higherspeeds, there is a tendency for injury to occur in theupper part of the cervical spinal column.Connective tissue recoveryDe Morree 15 presented a general model describingphysiological recovery in connective tissue afterdamage. This model describes three partlyoverlapping phases. These are the inflammatoryphase (0–4 days after tissue damage), the fibroblasticphase (4–21 days after) and the remodeling phase(3–6 weeks after). The inflammatory phase ischaracterized by local reactions to tissue damage. Thisphase’s duration depends on the extent of tissuedamage. After about four days, the formation of newconnective tissue begins in the so-called fibroblasticphase. This second phase lasts until the injuredregion is bridged by connective tissue. During this12V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashperiod, the load-bearing capacity of the connectivetissue is not yet very great. In the last phase,connective tissue strength increases. The tissue isrestructured into a form that can resist stretchingforces and in which tension corresponds to the forceexerted on the connective tissue. These phases maylast from many months to more than a year.performance of work, hobbies and sports. Thesymptoms most frequently reported immediatelyafter accidents are neck pain, decreased neckmobility, and headache. In addition, photophobia(i.e., an inability to stand bright light), dizziness,concentration problems, and fatigue may also occur(Table 6).Consequences of whiplashStudies on the consequences of whiplash injuryprovide no unequivocal conclusions on resultingimpairments in body structures. Review articlesdescribe a great number of anatomical structures thatmay be damaged: 9,16 facet joints, intervertebral disks,muscles, ligaments, atlantoaxial joints, the brain,cervical vertebrae, and the temporomandibular joint.However, imaging investigations carried out just afteraccidents mostly fail to show soft-tissue defects orindications of soft-tissue damage. 17,18Patients’ complaints after whiplash are very divers innature and duration. Whereas one person may haveno complaints after an accident, another may havecomplaints that last a few weeks, and yet anothermay have continuing complaints. Persistentcomplaints can lead to disabilities and problems withsocial participation that may affect, for example, theDefinition of whiplashIt is far from clear how to define whiplash. In theseguidelines, the definition formulated by the QuebecTask Force on whiplash-associated disorders has beenused because this is, at present, the most commonlyused definition: “Whiplash is an accelerationdecelerationmechanism of energy transfer to theneck. It may result from rear-end or side-impactmotor vehicle collisions, but can also occur duringdiving or other mishaps. The impact may result inbony or soft-tissue injuries (i.e., whiplash injury), thatmay, in turn, lead to a variety of clinicalmanifestations (i.e., whiplash-associateddisorders)”. 20The Quebec Task Force classified whiplash disorders(i.e., whiplash-associated disorder) on two axes: aclinical-anatomical axis and a time axis. The clinicalanatomicalaxis has five grades of severity: from 0 toTable 6. Percentages of patients reporting specific symptoms immediately (i.e., less than four weeks) and sixmonths after accidents involving whiplash. Source: Stovner. 19Symptoms Immediately after the accident Six months after the accidentNeck pain 90–100% 10–45%Decreased neck mobility 40–95% 14%Headache 50–90% 8–30%Photophobia 30–80% –Shoulder and arm pain 40–70% 5–25%Dizziness 20–70% 3–20%Concentration problems 20–60% 5–21%Fatigue 60% –Fear 45–50% 5–12%Reduced vision 20–45% 3%Depressive complaints 45% 5–10%Back pain 35% –Insomnia 35% –Elevated irritation 20% 9–14%Paresthesia in the hand 10–15% –Loss of libido – 7%V-09/2003/US13

KNGF-guidelines for physical therapy in patients with whiplash4 (Table 1). The time axis has six phases: phase 1covers the period up to four days after the whiplash;phase 2 lasts from four days to three weeks after;phase 3 from three to six weeks; phase 4 from sixweeks to three months; phase 5 from three to sixmonths; and phase 6 covers the period more than sixmonths after the whiplash. 20 This classification isbased on the physiological tissue recovery process.Figure 1. The cumulative percentage of patientsrecovering after whiplash reported by the Quebec TaskForce on whiplash-associated disorders, which definedrecovery is as “going back to work”.percentage of patients recoveringEpidemiologySkovron 21 published an overview of the epidemiologyof whiplash. The author reported that incidencefigures vary from 16 to 70 per 100,000 inhabitantswhen whiplash frequency is determined on the basisof insurance company claims. The variability isascribed to differences in the definition of whiplash,and to differences in road, traffic and populationdensity, driving behavior, the average distancebetween home and work, social legislation, liabilityinsurance, and car insurance. Using accidentstatistics, Wismans and Huijskens 21 estimated thenumber of new patients with whiplash traumas inthe Netherlands at 15,000 to 30,000 a year, in apopulation of about 16 million. This corresponds toan incidence of 94–188 per 100,000 inhabitants ayear.PrognosisThere is no consistency in the scientific literature onthe prevalence of long-term complaints afterwhiplash or on the course of whiplash-associateddisorders. Figures reported in studies show a widerange of variation, partly because of differences in thedefinitions used, in follow-up periods, and in thepurposes of the studies. 23–27 Literature reviews reflectthe diversity of results. Stovner 19 reported that sixmonths after accidents, 50–80% of affected personsare free of complaints, whereas Freeman et al. 28concluded that 19–60% of patients still hadcomplaints after six months. In general, however, theprognosis after whiplash is favorable. Data derivedfrom the Canadian research group, the Quebec TaskForce on whiplash-associated disorders, are frequentlyquoted. 20 They describe a relatively favorableprognosis, as shown in Figure 1.In patients with whiplash injuries, the medianrecovery time is 30 days, with recovery being definedweeksas “going back to work”. Some 25% of patientsrecover within one week and, after a year, 98% haverecovered. 29 The Quebec Task Force on whiplashassociateddisorders has criticized these data bystating that they underestimate both the severity andduration of the complaints experienced bypatients. 28,30 Furthermore, the Task Force stated that,although the study on which the figures were basedwas indeed extensive, it was carried out in just onecountry (i.e., Canada). It should be recognized thatphysical and psychosocial factors and thetechnicalities of insurance can also influence thereported prognostic data. 29 In a systematic review ofprognosis after whiplash, Verhagen et al. 31 concludedthat there are substantial differences between studiesin terms of their content as well as theirmethodology, and that the studies’ conclusions are,therefore, not very valid.Prognostic factorsRecent opinion about the occurrence of chroniccomplaints after whiplash injury holds thatpsychosocial factors are important in maintainingpain complaints. 30,32 In experiments in whichvolunteers suffered whiplash traumas, chroniccomplaints did not appear to result. Moreover, thereare apparently no chronic complaints after similarwhiplash-type traumas suffered during sportingactivities. The reason is thought to be that the testsubjects know that the neck complaints willdisappear after some time. It has also been suggested14V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashTable 7. Summary of factors found in the literature search that indicate an unfavorable prognosis for recoveryafter whiplash.1. Accident-related factors• decreased neck mobility 24,26• pre-existing head trauma 26,33• riding in a bus or truck 29• being a passenger 29• moving vehicle collision 29• frontal or side-impact collision 29• similar pre-existing complaint, such as headache 26• severe initial consequences of the accident, such as high-intensity neck pain, headache, or changes inpsychic or cognitive functioning 26• consequences of the accident, such as neck pain or headache, persisting after three or six months 322. Personal factors• female gender 23,29• older age 23,26,29• being a carer 29• no full-time job 29• ‘stressful life events’ 25that psychosocial factors explain the frequentlyobserved international differences in the prevalenceof chronic complaints after whiplash. 30 Thesuggestion is that psychological and cultural factorsare responsible for persistent pain behavior inpatients.Whiplash-related factors causing delayedrecoveryA systematic literature search for factors that areprognostic for delayed recovery after whiplash wascarried out using the following key words: whiplash,neck injury, neck sprain; prognosis, predictive,recovery, evolution; prospective, cohort. The searchwas performed using the MEDLINE and CINAHLdatabases, both from 1982 through June 2000. Inaddition, a manual literature search was also carriedout. The process produced 70 references. Thereafter,selection criteria were applied, namely: the articleshould be in English, French, German or Dutch; thestudy design should be prospective and involve acohort; the patients should have suffered whiplashinjuries; the publication should not describe theresults of specific interventions; and at least onemeasure of physical functioning should be used. Afterapplying these criteria, six studies remained. 23–26,29,33The result of the search are presented in Table 7. In it,a distinction is made between unfavorable prognosticfactors that were found in only one study and thosethat were found in more than one study. If differentstudies reported inconsistent findings on a particularprognostic factor, it was not included in the table.Overall, it can be said that knowledge about factorsthat are prognostic for delayed recovery from theconsequences of whiplash is limited. The only factorsthat were associated with unfavorable results in twoor more studies are decreased neck mobility directlyafter the accident, pre-existing head trauma, gender,and age. With regard to age, it is unclear where thecut-off point for an unfavorable prognosis lies. Theguidelines refer only to factors that have been foundto confer an unfavorable prognosis in more that onestudy.Chronic pain-related factors causing delayedrecoveryLinton 34 carried out a systematic review of therelationship between psychological factors and backand neck pain. In total, 36 prospective studies wereV-09/2003/US15

KNGF-guidelines for physical therapy in patients with whiplashincluded. On the basis of several high-quality studies,Linton concluded that psychosocial variables arestrongly related to the change from acute pain tochronic pain and disability. It also appears that, ingeneral, psychosocial variables have a greater impacton pain-related disability than bio-medical or biomechanicalfactors. The patient’s behavior, attitudeand emotions all play important roles. Passivecoping, ideas about pain that involve, for example,catastrophizing, and emotions such as depression andfear are all strongly related to pain and disability.There is also moderate to strong evidence that thesepsychosocial factors may predict the persistence ofpain and disability over the long term.Waddell and Waddell 35 carried out a systematicreview of the influence of social factors on back andneck pain. They concluded that there are strongindications that social factors are related to back andneck pain, but that studies into the topic are of onlymoderate quality. A number of social factors can berelated to pain on the basis of the findings of onesystematic review or of consistent findings in morethan two high-quality studies. These are: low socioeconomicclass and psychological aspects of work,such as poor job satisfaction. In addition, in patientswith neck pain, static load and repetitive movementare associated with pain and disability. 36 The authorsof the review emphasized that no social factor can bedescribed as a risk factor for pain, but that socialfactors may influence pain and the patient’s copingstrategy.Coping strategyPatients may cope with their complaints eitheradequately or inadequately, depending on whetherthey have an ‘active’ or ‘passive’ coping style. Copingis defined as: “the cognitive and behavioral effortsmade by an individual to control, reduce and toleratethe internal and external demands created by astressor”. 37 In active coping, individuals undertakeactions to control pain by themselves. For example,they seek distraction or move. In passive coping,individuals adopt a predominantly passive attitudeby, for example, resting, using medication, becomingdependent on others to control pain, or decreasingactivities to reduce pain. 38 Active coping is associatedwith better functioning, whereas passive coping isassociated with poorer functioning. 38 The way inwhich a person deals with his complaints is, amongother things, determined by the patient’s personalcharacteristics and by his interaction with hisenvironment, including his interaction with thephysical therapist.Patient characteristicsThe significance a patient attaches to his complaintsand the feeling of control he has over them are twoimportant characteristics. As it is based on thesubjective perception and interpretation of stimuli,the significance a patient attaches to his complaintsmay not correspond with objective reality. If this isthe case, the patient is making a logical error. Onecommon logical error is to ‘catastrophize’, that is toconsider the pain and the situation in which the painis present as being a serious threat (i.e., acatastrophe). In addition, the extent to which aperson feels he has control over his pain is alsoimportant. The patient may feel that his health ismainly controlled by himself (i.e., there is an internallocus of control) or that it is mainly controlled byother people or by circumstances (i.e., there is anexternal locus of control). Some individuals giveother people, for example, the physical therapist,control over their health. 39 An internal locus ofcontrol is often related to active coping and,subsequently, to a better way of dealing with pain. 38Both the significance attached to pain and theperceived sense of control may determine thepatient’s movement behavior. For instance, if pain isconsidered to be a sign of possible injury (i.e., thepatient catastrophizes), there is a significant risk thata fear of movement will result. This is the fear thatmovement will result in (new) pain or (re)injury. Itcan, in turn, lead to avoidance. 40 In addition, when,on the basis of previous experience, the patientexpects that a certain activity will increase pain in away over which he has no control, there is a risk thatthe situation giving rise to this activity will beavoided.Interaction between patient and environmentSocial support can help an individual deal withsetbacks and adjust to change. The most importantsource of social support is the patient’s partner.16V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashTable 8. Practical example of a pain-contingent approach to treatment which does not accord with behaviororientedprinciples.• The patient practices carrying by carrying a five-kilogram box for a certain distance. After walking up anddown once, the patient complains about pain. The box is put down and the patient rests briefly. Whileresting, the patient talks a little until “it’s time to go again”. Then the patient returns to carrying the box.• What is happening in this process? Carrying is being punished by pain, therefore carrying behavior willdecrease, and pain is being rewarded by rest and a nice conversation, therefore resting will increase. Thephysical therapist must avoid this negative reinforcement of a decrease in activity or movement.• Therefore, it is advisable to pay much more attention to activity and movement and, thereby, toincreasing them. The activity duration should be gradually increased in a time-contingent manner.Patients with pain who have good social supportrecover more quickly and return to normal dailyactivities sooner. On the other hand, certain kinds ofsocial support can also contribute to the maintenanceof complaints. For example, a partner who takeseverything out of the hands of the patient will, bydoing this, ensure that the patient’s logical errorspersist.and advice is provided. Cooperation betweenpractitioners of different disciplines is important andtreatment agreements made between differentpractitioners must be consistent. Guidelines on thefollowing topics have been developed to assistcommunication with primary care physicians:indication setting, letters of referral, consultation,contact during treatment, and writing reports. 41The physical therapist’s attitude and the way inwhich he approaches the patient’s complaints alsoappear to influence the course of the complaints. Inpatients suffering the consequences of whiplash overthe long term, it is very important to use a timecontingentapproach to treatment, as described belowin the section on behavior-oriented principles.Behavior-oriented principlesUsing behavior-oriented principles involves directingtreatment towards the patient’s behavior and thesituation producing the behavior rather than towardspossible underlying pathological factors orimpairments in body structures or body functions. 12In addition, the patient must actively participate intreatment and a time-contingent approach, meaningthat the therapeutic intervention is determined bytime and not pain, should be used. Table 8 describes apractical example of a pain-contingent approach totreatment which does not accord with behaviororientedprinciples.Interdisciplinary cooperationFor the patient, it is important that practitioners ofall the disciplines involved in treatment employ thesame principles and that unambiguous informationAdvisory note issued by the scientific board of theDutch Whiplash FoundationThis advisory note concerns the policy that shouldbe adopted by primary care physicians during theinitial treatment of whiplash patients. 42 The advisorynote states: “The patient’s pain should be treated asaggressively as possible for one week usingnonsteroidal anti-inflammatory drugs. The patientshould be advised to alter his activities but to stayactive at the same time.” The advisory note statesthat the use of a collar, including a soft collar, shouldbe limited to one week after the accident. Patientsare also advised and encouraged to make activehead-and-neck movements within the pain-freerange. There should be no passive movements.Furthermore, the advisory note makesrecommendations on patients’ performance ofnormal daily activities. Employers have to coordinatethe implementation of this advice with anoccupational physician. It should be noted that theseguidelines do not recommend wearing a collar sinceno evidence was found to support their use. Moreinformation is given in the description of thetherapeutic process below.V-09/2003/US17

KNGF-guidelines for physical therapy in patients with whiplashDiagnosisThe methodical application of physical therapyinvolves the adoption of a problem-solvingapproach. 43 This methodical approach involves thefollowing phases: referral, history-taking,examination, analysis (including the formulation of aphysical therapy diagnosis), drawing up a treatmentplan, providing treatment, evaluating treatment,drawing conclusions, and report writing. 44–46 In thissection of the review of evidence, some aspects ofhistory-taking, examination, and analysis arediscussed.History-takingTwo important aspects of history-taking are assessingthe patient’s coping strategy and condition at thetime of observation.1. Coping strategy. The physical therapist might ask:What are you yourself doing about yourcondition? Do you think it is effective? To whatextent do you fear that movement is harmful?What do you expect from therapy? Which goals(especially in terms of activities) do want toachieve?2. Assessment of status praesens. The physicaltherapist should ask systematically about thepatient’s different functions, activities and typesof participation (Table 9). The physical therapistshould also assess whether the demands made onthe patient by himself and his surroundingsmatch his load-bearing capacity.Measuring instrumentsVisual analogue scales. A visual analogue scale canprovide a reliable, valid and simple way of measuringpain. 47 These types of scales can also be used to assessother subjective variables, such as fatigue,functioning and quality of life. 48 It is recommendedthat visual analogue scales are used to evaluate the‘most important complaints’ in patients suffering theconsequences of whiplash. These may be, forexample, pain intensity or fatigue. In essence, a visualanalogue scale consists of a horizontal line 10 cm inlength on which the patient indicates the severity ofhis most important complaint by marking a narrowTable 9. Examples of functions, activities and types of participation. 10Functions:• mental functions: sleep behavior, attention span, memory, thought processes, language use, countingability, and mood;• sensory functions: senses of vision, hearing, balance and taste;• locomotion: joint and bone function (e.g., mobility and stability), muscle function (i.e., strength, tonusand endurance), and movement patterns (gait, involuntary movements, and voluntary movements).Activities:• basic movements: maintaining or changing body posture, and carrying, moving and manipulatingobjects;• moving from place to place: walking and using transport;• self-care activities: washing, dressing, eating and drinking;• domestic activities: preparing meals, taking care of property, and assisting others.Participation in:• personal care;• mobility (inside and outside the home);• social activities;• domestic life and helping others;• education;• work or profession;• social and community activities, including recreational and free-time activities.18V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashvertical line. The wording ‘no complaints’ is writtenat the left end of the scale and ‘very severecomplaints’ at the right end. The distance betweenthe left end of the scale and the vertical line markedby the patient indicates the severity of the patient’smost important complaint. The time period to whichthe assessment applies must be standardized. Forexample, by asking: What was the severity of yourmost important complaint during the last week?Neck disability index. The neck disability index 49 isbased on a questionnaire about the symptoms,disabilities and participation problems that patientsmay experience as a consequence of whiplash. Thequestionnaire consists of 10 items: pain intensity,headache, concentration ability, sleep behavior,lifting ability, working ability, car-driving ability,recreational activities, performing personal care, andreading habits. The 10 items are scored on an ordinalscale from 0–5 and the maximum score is 50.patient indicates how much time he spends on thesedifferent activities and how his complaints areinfluenced by these activities (i.e., increased,decreased or unchanged). This process helps thephysical therapist obtain some insight into the typeand duration of the patient’s different activities andthe influence that the patient’s complaints has on theperformance of these activities. By combining theactivity list with the results of carrying out a visualanalogue scale assessment for each activity, itbecomes clear which activities result in numerouscomplaints and which result in only a few. Moreover,by noting what the patient does when the level of acomplaint increases (e.g., taking medication orseeking distraction), the physical therapist can seehow the patient copes with his complaints in termsof his activities. This information can be used toformulate an individual treatment plan for thepatient. Moreover, it can indicate the type of advicethat should be given and can aid evaluation.The results of an early study carried out by Vernonand Mior 49 indicate that the neck disability index is areliable and responsive measure in patients sufferingthe consequences of whiplash. In a later review,Vernon 50 reported that several studies confirmedthese earlier findings. Vernon concluded that theneck disability index is a useful measuring instrumentfor whiplash patients which can be used ininvestigations as well as in daily practice. Stratford etal. 51 estimated that the smallest change that can bedetected using the index is 4.7 points. This meansthat, in practice, if there is a five-point difference orgreater between the patient’s index score beforetreatment and the score after treatment, the patient’ssymptoms, disabilities and participation problemsreally have changed. If the difference is three pointsor less, it is unlikely that a change has occurred,whereas a difference of seven points or moreindicates a significant change. The neck disabilityindex can be applied by the patient himself.Answering the questionnaire takes three minutes onaverage.Daily diary. The patient is asked to keep a list ofactivities for one week. He must write down thedifferent types of activity he is involved in on about10 occasions throughout the day. Subsequently, thePhysical examinationPhysical examination forms part of the diagnosticprocess. The examination strategy adopted dependson the information obtained during history-taking.Test for examining functionsThe co-ordination test described by Lanser 52 andVerhagen et al. 53 can be used to assess muscularstability of the cervical spine. In this test, the patientlies in supine position while the physical therapistpushes gently in a ventral direction. The patient isasked to resist this pressure. The test result is positivewhen there is no local reaction in the cervicalmuscles. A study carried out by Verhagen et al. 31indicated that patients who are suffering theconsequences of whiplash have a positive result moreoften than healthy individuals.Balance testsBrinkman et al. 54 described five tests of balance:walking along a raised wooden plank, Romberg’s test,standing on one leg, adopting a tightrope walker’sgait, and hopping. Three of these tests are notcovered by these guidelines: Romberg’s test andwalking along a raised wooden plank are excludedbecause patients suffering the consequences ofwhiplash almost always have maximum scores onV-09/2003/US19

KNGF-guidelines for physical therapy in patients with whiplashthese tests, and the hopping test is excluded becauseit appears to be unreliable. 55 However, the followingare recommended:• Standing on one leg: In this test, the patientstands for as long as possible on one leg (for amaximum of 30 seconds). In turn, the patientstands on his dominant and, then, non-dominantleg. The patient makes two attempts on each leg.The arms are positioned alongside the body. Thepatient may move his torso a little so long as hisfoot remains on the ground. The number ofseconds the patient can stand is noted andconstitutes the final score.• Tightrope walker’s gait: In this test, the patientwalks very slowly along a 3-meter long line on theground, stepping heel to toe. After one practiceattempt, the test must be performed as quicklyand precisely as possible while the physicaltherapist records the time taken using astopwatch. Three seconds are added to the finaltime for each mistake made, such as when thefoot is not placed on the line or when the heeldoes not touch the toe. Finally, a total score iscalculated (i.e., the final time plus any penaltytimes) by taking the mean of the scores from twoattempts.Carrying out an otoneurologic examination, such asRomberg’s test or Unterberger’s test, is notrecommended for physical therapy diagnosis inpatients suffering the consequences of whiplashbecause these tests have little diagnostic value. 54,56AnalysisDuring treatment, a distinction is made betweenwhiplash patients in whom recovery is normal andthose in whom recovery is delayed. Thecharacteristics of delayed recovery may include:• persistent pain;• a decreased level of activity or social participation;• more general complaints, such as fatigue, poorergeneral physical load-bearing capacity, ordepressive complaints;• increasing fear of movement;• no response to treatment; and• increasing patient requests for medicalexamination or treatment.In the analysis, it is decided whether physical therapyis indicated and whether the guidelines can befollowed during treatment on the basis of referraldata combined with the results of history-taking andthe physical examination.TherapyIn this section, firstly, evidence supporting thetherapeutic process adopted is presented and,subsequently, the process is described. Guidelinerecommendations are based on a systematic search ofthe literature on the effectiveness of physical therapyin patients suffering the consequences of whiplash.The search was carried out using the followingdatabases: MEDLINE (1982 through June 2000), CINAHL(1982 through June 2000), the Cochrane Library(1999:4), and the database of the Dutch Institute ofAllied Health Professions (NPi) documentation center(up to July 2000). The keywords used were: whiplash,neck injury, neck sprain; physical therapy,physiotherapy, behavioral therapy, massage,education, manipulation, mobilization,electrotherapy; systematic review, meta-analysis,randomized clinical trial and randomized controlledtrial. In addition, literature was provided by membersof the working group and was sought manually.The literature search on the effectiveness of physicaltherapy in patients suffering the consequences ofwhiplash resulted in 35 publications. For inclusion,the following criteria also had to be satisfied: thepublication had to be in English, German, French orDutch; the publication had to describe a systematicreview, a meta-analysis or a randomized clinical trial;the study had to concern only whiplash patients; andthe treatment used had to involve physical therapyinterventions and other intervention that lie withinthe scope of physical therapy as applied in theNetherlands. After applying these criteria, 14publications remained.A second search was performed, this time on theeffectiveness of physical therapy in chronic pain.Here, in part, the same keywords were used as in thefirst search. The difference was that the patientpopulation was defined by the keyword ‘chronicpain’. This search generated 100 publications. The20V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashinclusion criteria with regard to publication languageand to the interventions used were the same as forthe first search. In addition, the following criteriawere important: the design had to be a systematicreview or a meta-analysis; and the study had toinvolve persons with chronic benign pain of thelocomotor (i.e., musculoskeletal) system. Studiesinvolving combined groups of patients or patientswith specific disorders such as rheumatism orosteoarthritis were excluded. After applying thesecriteria, six publications remained.Supporting evidenceEvidence on the effectiveness of physical therapyafter whiplashPeeters et al. 57 performed a systematic review ofconservative treatment in patients with whiplashinjuries. Eleven studies were included. Three were ofsufficiently high methodological quality. 58–60 Thestudy by Foley-Nolan et al. 58 investigated the efficacyof pulsed high-frequency electromagnetic therapy, 27MHz for eight hours a day, provided by a small devicebuilt inside the collar. However, as such devices arenot available in the Netherlands, this interventionfalls outside the scope of physical therapy in thecountry and, thus, the findings were not considered.The study by Provinciali et al. 59 comparedmultimodal treatment, which included acombination of relaxation, postural and eye-fixationexercises, counseling, and manual techniques, withdifferent physical modalities, includingtranscutaneous electrical nerve stimulation (TENS),pulsed high-frequency electromagnetic therapy,ultrasound therapy and iontophoresis. The averagetime that had passed since the patients experiencedthe whiplash injuries was 30 days. Over the shortterm as well as the long term, multimodal treatmentwas found to have more positive effects in terms ofpain and ‘global’ effect. Moreover, the patients whoreceived multimodal treatment went back to worksooner than those who received treatment with thephysical modalities. Provinciali et al. recommendmultimodal treatment in patients with complaintsdue to whiplash. The study by Borchgrevink et al. 60examined the long-term effects of the advice that wasgiven in the first 14 days after the accident. Onegroup was advised to stay active, while the other wasadvised to rest for 14 days and to wear a soft collar.After six months, symptoms had decreased in bothgroups. Patients in the group that was advised to stayactive experienced less pain and stiffness. On thebasis of these results, it can be concluded, with somecaution, that active interventions have a morepositive influence on the chosen outcome parametersthan resting in patients with whiplash injuries. Theseresults are supported by three other studies, which aremethodologically of poor quality. 61–63 Anothermethodologically poor-quality study found nodifference between immobilization and no treatmentat all. 64Peeters et al.’s conclusions are, to a large extent, inagreement with those of Magee et al. 65 and those ofthe Quebec Task Force. 20 Magee et al. 65 carried out asystematic review of the effectiveness of physicaltherapy interventions for neck injury after trauma.The review covered eight studies, among which werethree that had no control groups or in which patientswere not randomized, or both. All studies wereconsidered as methodologically poor. The resultsshowed that exercise, manual therapy and posturaladvice are all moderately effective in whiplashpatients. They also indicated that the use of a collaror resting is ineffective in this group of patients. Theauthors emphasized the need for good-qualityrandomized clinical trials in this area. In 1995, theQuebec Task Force published a ‘best evidence’synthesis on, among other subjects, the mosteffective treatments in whiplash patients. The authorsconcluded that use of a collar does not decrease neckmobility and that wearing a collar can lead to generalinactivity, which can delay recovery in this group ofpatients. They also concluded that long periods ofrest can harm recovery and that mobilizing exercisescan be used in addition to actively encouragingactivity. Furthermore, the authors stated that exerciseused as part of multimodal interventions may havepositive short-term and long-term effects. A study ofthe effects of traction showed no statisticallysignificant clinical effects. The effectiveness ofimproving and giving advice on posture,electrotherapy, ultrasound therapy, laser therapy,short-wave therapy, the application of warmth, theapplication of ice, and massage was not studied,although some interventions were used incombinations as control interventions. The studiesV-09/2003/US21

KNGF-guidelines for physical therapy in patients with whiplashon high-frequency electrotherapy 58,66 were coveredby Peeters et al.’s review.A more recent randomized clinical trial 67 was notincluded in the above-mentioned reviews. In thisstudy, the effects of treating whiplash patients byearly mobilization were compared to the effects ofstandard treatment, comprising rest, receiving advice,and use of a collar. In addition, the trial investigatedwhether it is more beneficial to start treatment early(i.e., within four days after the accident) or late (i.e.,14 days after the accident). Early treatment usingmobilization comprised active exercises, in whichrecurrent movements in different directions werepracticed each hour, and postural improvement,which was carried out in accordance with McKenzie’sprinciples. Standard treatment comprised receivingan information brochure containing advice onactivities and instructions on postural correction,resting, and use of a soft collar, followed severalweeks after the accident by the start of a program ofactive movements carried out two to three times aday. The researchers concluded that activemobilization produced better results after six months,in terms of less pain, than standard treatment.Moreover, the effects of early mobilization werebetter when treatment was started within four days,whereas starting standard treatment after 14 daysproduced better results.Evidence on the efficacy of physical therapy inchronic painMorley et al. 68 performed a systematic review andmeta-analysis of the efficacy of treatment programsthat followed behavior-oriented principles in adultswith chronic pain. They concluded that theseprograms were especially effective in influencing painbehavior, the level of pain experienced, mood, andsocial functioning compared to no treatment. Grosset al. carried out two literature reviews of theeffectiveness of conservative treatment in patientswith mechanical neck pain: one concerned theeffectiveness of physical therapy interventions 69 andthe other, the effectiveness of providing patienteducation. 70 The authors concluded that the studiesthey found gave little information on theeffectiveness of physical therapy interventions or onpatient education in those with mechanical neckpain. The most important reason for this conclusionwas the poor methodological quality of the studies.Furthermore, the search carried out for the reviewswas limited to the period 1985–1993. It was alsonoted that the effectiveness of providing informationand advice as a separate intervention in rehabilitationprograms for patients with chronic complaintscannot always be demonstrated. However, combiningexercise therapy and psychoeducational interventions(e.g., individual instruction, information programs,self-efficacy programs, informative material, andbehavioral therapy) in the form of multimodaltherapy can increase the effects of the treatment. 71,72Van Tulder et al. 73 delineated the efficacy of severaldifferent types of conservative treatment for chroniclow back pain with the help of a systematic review.They concluded that there are strong indications thatexercise therapy and multidisciplinary programs areeffective in patients with chronic low back pain. Inaddition, there were moderately strong indicationsthat behavioral programs and ‘back schools’ areeffective. There were no clear indications on whetheradvice to stay active, bed rest, physical treatmentmodalities, or transcutaneous electrical nervestimulation are effective. Biofeedback usingelectromyography and traction were found to beineffective.Hilde and Bø 74 performed a systematic review of theefficacy of exercise in patients with low back pain. Init, they evaluated whether any differences in theresults found could be explained by differences in themethodological quality, type or intensity of theexercises given. They concluded that these variablesdid not explain the differences found in the efficacyof the exercises used for chronic low back pain.Implications for the guidelinesOn the basis of the results of two controlled studies,these guidelines recommended not wearing a collar.Patients who are wearing collars on referral forphysical therapy should be advised to reduce theiruse. In patients with whiplash injury, activetreatment seems to give better results than passivetreatment. Therefore, an active policy has beenadopted in these guidelines and patients areencouraged to take up activities again and to22V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashparticipate socially again as soon as possible. Neitherthe effectiveness of adopting a behavior-orientedapproach nor of providing information has beenspecifically studied in patients suffering theconsequences of whiplash. However, because the useof behavior-oriented principles has positive effects inpatients with chronic pain, these guidelines advisethe use of behavior-oriented principles in patientssuffering the consequences of whiplash. Moreover,because patient education used in combination withexercise therapy is more effective than exercisetherapy alone in patients with chronic complaints,this combination is recommended in theseguidelines.Description of therapyPhase 2 (four days to three weeks after theinjury)During therapy, a distinction is made betweenpatients whose recovery is normal and those whoserecovery is delayed. When recovery is delayed, thepatient’s coping strategy might play an importantrole. For example, the patient may start too manyactivities too soon or too few activities too slowly.Nordin 75 outlined the ideas on providinginformation and advice produced by the Quebec TaskForce on whiplash-associated disorders. Patientsshould be reassured by explaining to them that mostconsequences of whiplash are self-limiting andbenign. It should also be explained that, although itmay be a little painful, movement is not harmful ingrade-1 whiplash-associated disorders. In grade-2whiplash-associated disorders, activity should beincreased after consultation with the primary carephysician or physical therapist.In the guidelines, a distinction is made betweentraining and exercising. The term training refers toworking according to physiological trainingprinciples, for example, to improve muscle functionor general stamina. An example would be training atan intensity of 60–70% of maximum muscle strengthor maximum heart rate three times a week.Exercising, on the other hand, does not necessarilyhave to follow these training principles. There areother goals, such as decreasing fear of movement orimproving coordination.Providing information and adviceEffective education requires knowledge, educationalskills, and the use of some behavioral techniques. Vander Burgt and Verhulst 76 presented an overview of thedifferent educational models used in counseling andtranslated them into a patient education model foruse by allied health professionals. They integrated theAttitude, Social Influence and Personal Efficacydeterminant model with Hoenen et al.’s step-by-stepeducational model. 77 In the Attitude, Social Influenceand Personal Efficacy determinant model, it ishypothesized that readiness to change behavior isdetermined by an interplay between the patient’sattitude (how the individual perceives the change inbehavior), social influences (how others see thechange in behavior), and the patient’s perception ofhis own efficacy, his self-efficacy (whether the patientthinks it will work or not). Hoenen et al.’seducational model identifies the steps of ‘beingopen’, ‘understanding’, ‘wanting’ and ‘doing’. Withthe practice of allied health professionals in mind,van der Burgt and Verhulst added another two steps:‘being able’ and ‘keeping on doing’. Van der Burgtand Verhulst regard education as a process in whichthe maintenance of new behavior is the last step. Thisfinal step cannot be taken if the preceding steps havenot been completed. Hence, the six steps must betaken in succession (Table 10). The physical therapistmust have knowledge about and an insight into thefactors that influence the desired behavioral change,whether positively or negatively.Education planThe physical therapy treatment program shouldinclude a separate education plan for the patient, inwhich subgoals are formulated for each step (Table11). The education plan should be seen as acomponent of the methodical approach adopted toproviding physical therapy. During history-taking,the patient’s need for information is assessed: it mustbe determined what the patient knows about thedisorder, about any medications that may have to betaken, and about healthy lifestyles. For each of theseitems, attention must be paid to any problems thepatient encounters. As a consequence, this approachcan provide an insight into the possible causes of anyproblems the patient has in complying with therapyor with adopting a healthy lifestyle. In evaluating theV-09/2003/US23

KNGF-guidelines for physical therapy in patients with whiplashTable 10. The six steps in the process of patient education.1. Being open: the physical therapist acknowledges the patient’s experiences, expectations, questions andworries.2. Understanding: information must be presented in such a way that the patient is able to understand andremember it.3. Wanting: the physical therapist evaluates what does or does not drive the patient to exhibit a certainbehavior. The physical therapist offers support and provides information about alternative possibilities.4. Being able: the patient must be able to perform the desired behavior. Functional activities are exercised.5. Doing: the physical therapist makes clear, specific, feasible agreements with the patient, sets specifictargets, and evaluates the extent to which the patient is able to satisfy the agreements.6. Keeping on doing: during treatment, the physical therapist must talk with the patient about whether ornot he thinks he will be able to exhibit and continue to exhibit the new behavior.provision of information and advice, the physicaltherapist can asks himself: “Does the patient knowwhat he should know? Is he doing what he shoulddo?”Exercise therapyExamples of relevant exercises are:• when there is impaired cervical muscle stability,isometric contractions should be practiced in thearea concerned, with contractions being adaptedto suit functional situations;• when there is impaired balance or dizziness,improvement is sought by practicing themaintenance of balance while standing andwalking. It is possible to vary position (e.g., thesize of a supporting surface or its center ofgravity), tempo (e.g., by slowing down oraccelerating) and visual control (e.g., by fixing theline of vision on a fixed or moving point).Phases 3, 4 and 5 (from three weeks onwards)Treatment aims to enable patients to bear activityor, if necessary, to learn new activities. This processis gradually expanded by means of a program inwhich activities are progressively performed forlonger (i.e., operant reconditioning using ‘gradedactivity’). The purpose of the program is to increasethe patient’s activity level and to decrease painbehavior. The ultimate goal is to achieve the desiredlevel of activity despite the presence of pain. 12Treatment starts with a baseline assessment in whichthe lengths of time the patient is able to perform thechosen activities are measured. Subsequently, atreatment plan is devised which enables the desiredfinal goal to be achieved from the baseline levelwithin the treatment period. In the first treatmentsession, the time during which the activity isexercised is less than that in the mean baselinemeasurement. Gradually, activities are performed forlonger. One of the agreements made abouttreatment is that the patient should exercise for noless, but also no more, than the agreed duration.Also, the patient should exercise at home and recordhis own progress. If the patient wants to perform anactivity he is not yet able to perform, that activityshould be divided into a number of separate parts.Each part should be exercised sequentially so that,eventually, the patient is able to perform the wholeactivity.Examples of relevant exercises• Attention span and memory can be improved bythe performance of double tasks such as countingor catching a ball while walking. The physicaltherapist can also advise the patient to increasegradually his performance of complex tasks suchas solving crossword puzzles or readingnewspapers. These can be assignments to becarried out at home.• For cervical spine impairment, exercises are givento mobilize the neck. Subsequently, the differentexercises are extended to include functionalsituations such as visually following a moving ball.24V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashTable 11. The details of providing information and advice to patients suffering the consequences of whiplash.Source: Treatment protocol for the whiplash trial. 78Providing information and advice forms part of counseling. The physical therapist acknowledges thepatient’s pain symptoms, answers the patient’s questions, and clears up any uncertainties the patient mayhave.Providing information and advice on:• the benign natural course of recovery from the consequences of whiplash;• the absence of severe pathology;• the active and influential role the patient has with regard to his own recovery;• movement, including the fact that movement is harmless;• body posture with regard to work, housekeeping, hobbies and sporting activities, including:- the influence of postures that place a long-lasting static load on the cervical spine (e.g., when readinga book, watching television or painting the ceiling); these postures have to be avoided during the firsttwo weeks of treatment;- ergonomic factors affecting the workplace and working posture;- aspects of personal care (e.g., the need to avoid washing hair in the sink);- sporting activities (e.g., the need to avoid jarring movements, sporting activities involving physicalcontact, and sporting activities involving the lengthy use of one side of the body, and the importanceof activities involving movement in general);• the balance between load and load-bearing capacity;• the influence of prognostic factors related to the cause and persistence of complaints (e.g., biopsychosocialfactors), including:- the influence of coping strategy on the maintenance of complaints;- the influence of fear of movement on the maintenance of complaints;• the importance of consistently performing exercises and activities at home to achieve the optimaltreatment result.Learning about activities in terms of:• the structured division of the day into alternate periods of loading and periods of recovery. The timeduring which the load is applied is determined by the mean time during which the patient can performthe activities without symptoms increasing;• performing activities in a time-contingent manner (with regard to loading);• adjusting the level of activity with respect to recovery. (Which activities increase symptoms and howlong do these activities have to be performed?);• coping with possible exacerbations or recurrences (in this, the balance between load and load-bearingcapacity must be taken into account).Conclusion and reportingThe KNGF guidelines entitled “Communicating withand reporting back to general practitioners” 79stipulate that the referring physician should beinformed at the end of the treatment, and possiblyalso during treatment, about the patient’s individualtreatment goals, the treatment process, and theresults of treatment, among other things. Details ofhow reports should be written are given in the KNGFguidelines entitled “Physiotherapeuticdocumentation and reporting”. 80Legal significance of the guidelinesThese guidelines are not statutory regulations. Theyprovide knowledge and make recommendationsbased on the results of scientific research whichV-09/2003/US25

KNGF-guidelines for physical therapy in patients with whiplashhealthcare workers must take fully into account ifhigh-quality care is to be provided. Since therecommendations mainly refer to the average patient,healthcare workers must use their professionaljudgement to decide when to deviate from theguidelines if that is required in a particular patient’ssituation. Whenever there is a deviation fromguideline recommendations, it must be justified anddocumented. 1,2 Responsibility, therefore, resides withthe individual physical therapist.RevisionsThese KNGF guidelines are the first such clinicalguidelines to be developed for diagnosis, treatmentand prevention in patients suffering theconsequences of whiplash. Subsequent developmentsthat could lead to improvements in the application ofphysical therapy in this group of patients may havean impact on the knowledge contained in theseguidelines. The prescribed method for developing andimplementing guidelines proposes that all guidelinesshould be revised a maximum of three to five yearsafter the original publication. 1,2 This means that theKNGF, together with the working group, will decidewhether these guidelines are still accurate by 2006 atthe latest. If necessary, a new working group will beset up to revise the guidelines. These guidelines willno longer be valid if there are new developments thatnecessitate a revision.Before any revision is carried out, the recommendedmethod of guideline development andimplementation should also be updated on the basisof any new knowledge and to take into account anycooperative agreements made between the differentgroups of guideline developers working in theNetherlands. The details of any consensus reached byEvidence-Based Guidelines Meetings (i.e., the EBROplatform), which are organized under the auspices ofthe (Dutch) Collaborating Center for QualityAssurance in Healthcare (CBO), will also be taken intoaccount in any updated version of the method ofguideline development and implementation. Forexample, the stipulation that uniform andtransparent methods are necessary for determiningthe amount of evidence needed and for derivingpractice recommendations would constitute animportant improvement.External financingThe production of these guidelines was subsidized bythe (Dutch) Ministry of Public Healthcare, Welfareand Sport (VWS) within the framework of a programentitled “A quality support policy for allied healthprofessions (OKPZ)”. The interests of the subsidizingbody have not influenced the content of theguidelines or the resulting recommendations for dailypractice.AcknowledgementsFor their help in producing the KNGF guidelines onwhiplash-associated disorders, special words ofgratitude to the multidisciplinary working committeeare in order. Many thanks to (in alphabetic order): PFvan Akkerveeken PhD (orthopedic surgeon, RugAdvies Centra Nederland), AWM Evers MSc(psychologist, St Radboud Medical Center, Nijmegen,the Netherlands), H Filarski (chairman of the DutchWhiplash Foundation), G Hermans PhD (medicaladvisor and manager of a project on “the assessmentof early determinants for distinguishing whiplashassociateddisorders”, Whiplash Center, theNetherlands), H Kingma PhD (inner ear specialist,Academic Hospital, Maastricht, the Netherlands),BGM Kolnaar PhD (primary care physician, DutchCollege of General Practitioners), CJ Vos MSc(primary care physician and scientist, ErasmusUniversity, Rotterdam, the Netherlands), JP vanWingerden (head of therapy, Spine and Joint Center,Rotterdam, the Netherlands). In addition, we wouldlike to thank all the physical therapists who have cooperatedin guideline evaluation in the field. Finally,we would like to thank JWS Vlaeyen (psychologist,University of Maastricht, the Netherlands), AJ EngersMSc (werkgroep Onderzoek Kwaliteit, KatholicUniversity of Nijmegen, the Netherlands), MM KlaverPhD (neurologist, Midden Twente hospital, theNetherlands), YF Heerkens PhD (Dutch Institute ofAllied Health Professions), CWM Neeleman-van derSteen MSc (Whiplash project group), AC de Visser(Whiplash project group) and EMHM Vogels (DutchInstitute of Allied Health Professions) for theircontribution to the guidelines.26V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplashGlossaryActivityExecution of a task or action by an individual95% confidence interval A range of values within which there is a 0.95 probability that the real value of ameasured parameter is includedDisabilityInability to perform an activity in the manner or to the extent considered normalfor that person(Body) functions Physiological functions of body systems (including psychological functions)ImpairmentProblem with body function or structure, such as a significant deviation or lossMeta-analysisAn overview article which involves a systematic search of the scientific literature.A single conclusion is reached by (quantitatively) combining the results of all thestudies foundParticipationInvolvement in a life situationParticipation restriction Problem an individual may experience with involvement in a life situation(Body) structure Anatomical part of the body, such as an organ or limb or its componentSystematic review An overview article which involves a systematic search of the scientific literature.The conclusions describe (qualitatively) the results of all the studies foundV-09/2003/US27

KNGF-guidelines for physical therapy in patients with whiplashReference list1 Hendriks HJM, Reitsma E, van Ettekoven H. Centrale richtlijnenin de fysiotherapie. Ned Tijdschr Fysioth 1996;106:2-11.2 Hendriks HJM, van Ettekoven H, Reitzma E, Verhoeven ALJ, vander Wees PJ. Methode voor centrale richtlijnontwikkeling enimplementatie in de fysiotherapie. Amersfoort, the Netherlands:KNGF/NPi/CBO; 1998.3 Hendriks HJM, van Ettekoven H, van Wees PJ. Eindverslag vanhet project Centrale richtlijnen in de fysiotherapy (Deel 1).Achtergronden en evaluatie van het project. Amersfoort, theNetherlands: KNGF/NPi/CBO; 1998.4 Hendriks HJM, Bekkering GE, van Ettekoven H, Brandsma JW,van der Wees PJ, de Bie RA. Development and implementationof national practice guidelines: A prospect for continuous qualityimprovement in physiotherapy. Introduction to the method ofguideline development. Physiotherapy 2000;86:535-47.5 Scholten-Peeters GGM, Bekkering GE, Hendriks HJM,Oostendorp RAB. KNGF-guideline Whiplash: een vroegtijdigeactieve benadering. Fysiopraxis 2001;9:28-32.6 Deskundigheidsbevorderingspakket KNGF-richtlijn Whiplash.Fysiopraxis 2001;9(supplement).7 Oostendorp RAB, Hendriks HJM, Scholten-Peeters GGM, van derSteen CWM. Deskundigheidsbevorderingspakket ten behoevevan de implementatie van de KNGF-richtlijn Whiplash.Amersfoort, the Netherlands: KNGF/NPi; July 11, 2002.8 Hendriks HJM, van Ettekoven H, Bekkering T, Verhoeven A.Implementatie van KNGF-richtlijnen. Fysiopraxis 2000;9:9-13.9. Barnsley L, Lord S, Bogduk N. Clinical review: whiplash injury.Pain 1994;58:283-307.10 World Health Organization (WHO). ICIDH-2: InternationalClassification of Impairments, Activities and Participation: amanual of dimensions of disablement and functioning. Geneva,Switzerland: WHO; 1997.11 Faas A, Chavannes AW, Koes BWE, van den Hoogen JMM, MensJMA, Smeele LJM et al. NHG-standaard Lage-Rugpijn. HuisartsWet 1996;39:18-31.12 Vlaeyen JWS, Kole-Snijders AMJ, van Eek H. Chronische pijn enrevalidatie. Praktijkreeks Gedragstherapie. Houten, theNetherlands: Bohn Stafleu Van Loghum; 1996.13 KNGF. Kwaliteitscriteria voor de fysiotherapeutische behandelingin groepsverband. Amersfoort, the Netherlands: KNGF; 1995.14 Panjabi MM, Cholewicki J, Grauer JN, Babat L, Dvorak J.Mechanism of whiplash injury. Clin Biomech 1998;13:239-49.15 De Morree JJ. Dynamiek van het menselijk bindweefsel: functie,beschadiging en herstel. Houten, the Netherlands: Bohn StafleuVan Loghum; 1996.16 Bogduk N. The anatomy and pathophysiology of whiplash. ClinBiomech 1986;1:92-101.17 Ronnen HR, de Korte PJ, Brink PRG, van der Bijl HJ, Tonino AJ,Franke CL. Geen indicatie voor MRI-onderzoek van patiëntenmet acuut whiplash trauma: een prospectief onderzoek bij 100patiënten. Ned Tijschr Geneeskd 1997;141:1858-63.18 Rauschning W, Jonsson H. Injuries of the cervical spine inautomobile accidents: pathoanatomical and clinical aspects. In:Gunzberg R, Szpalski M, editors. Whiplash injuries: currentconcepts in prevention, diagnosis and treatment of the cervicalwhiplash syndrome. Philadelphia and New York: Lippincott-Raven Publishers; 1998.19 Stovner LJ. The nosologic status of the whiplash syndrome: acritical review based on a methodological approach. Spine1996;21:2735-46.20 Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J,Suissa S et al. Scientific monograph of the Quebec Task Force onWhiplash-associated disorders: redefining ‘Whiplash’ and itsmanagement. Spine 1995;20:7S-58S.21 Skovron ML. Epidemiology of whiplash. In: Gunzberg R, SzpalskiM, editors. Whiplash injuries. Current concepts in prevention,diagnosis and treatment of the cervical whiplash syndrome.Philadelphia and New York: Lippincott-Raven Publishers;1998:61-8.22 Wismans KSHM, Huijskens CG. Incidentie en preventie van het‘whiplash’-trauma. TNO-report 94.R.BV.041.1/JW. Delft, theNetherlands: TNO Road-Vehicles Research Institute; 1994.23 Squires B, Gardan M, Bannister G. Soft-tissue injuries of thecervical spine. J Bone Joint Surg 1996;78-B:955-7.24 Gargan M, Bannister G, Main C, Hollis S. The behaviouralresponse to whiplash injury. J Bone Joint Surg 1997;79-B:523-6.25 Karlsborg M, Smed A, Jespersen JH, Stephensen S, Cortsen M,Jennum P et al. A prospective study of 39 patients with whiplashinjury. Acta Neurol Scand 1997;95:65-72.26 Radanov BP, Begré S, Sturzenegger M, Augustiny F. Course ofpsychological variables in whiplash injury: a 2-year follow-upwith age, gender and education pair-matched patients. Pain1996;64:429-34.27 Obelieniene D, Schrader H, Bovim G, Miseviciene I, Scand T.Pain after whiplash: a prospective controlled inception cohortstudy. J Neurol Neurosurg Psychiatry 1999;66:279-83.28 Freeman MD, Croft AC, Rossignol AM. ‘Whiplash associateddisorders: redefining whiplash and its management’ by theQuebec Task Force. A critical evaluation. Spine 1998;23:1043-9.29 Harder S, Veilleux M, Suissa S. The effect of socio-demographicand crash-related factors on the prognosis of whiplash. J ClinEpidemiol 1998;51:377-84.30 Ferarri R, Russell AS. Epidemiology of whiplash: an internationaldilemma. Ann Rheum Dis 1999;58:1-5.31 Verhagen AP, Sijpkes P, de Vet W. Behandeling van whiplash: eensystematische review. Ned Tijdschr Fysiother 1996;5:135-41.32 Ratliff AHC. Whiplash injuries. J Bone Joint Surgery 1997;79-B:517-9.33 Radanov BP, Sturzenegger M, Di Stefano G, Schnidrig A,Aljinovic M. Factors influencing recovery from headache aftercommon whiplash. BMJ 1993;307:652-5.34 Linton SJ. Psychological factors in neck and low back pain. In:Nachemson AN, Jonsson E, editors. Neck and back pain: thescientific evidence of causes, diagnosis and treatment. New York:Lippincott Williams & Wilkins; 2000.35 Waddell G, Waddell H. Social influences on neck and low backpain. In: Nachemson AN, Jonsson E, editors. Neck and backpain: the scientific evidence of causes, diagnosis and treatment.New York: Lippincott Wilkins; 2000.36 Vingård E, Nachemson A. Work-related influences on neck andlow back pain. In: Nachemson AN, Jonsson E, editors. Neck andback pain: the scientific evidence of causes, diagnosis andtreatment. New York: Lippincott Wilkins; 2000.37 Folkman S, Lazarus RS. An analysis of coping in a middle-agedcommunity sample. J Health Soc Behav 1980;21:219-39.38 Jensen MP, Turner JA, Romano JM, Karoly P. Coping withchronic pain: a critical review of the literature. Pain 1991;47:249-83.28V-09/2003/US

KNGF-guidelines for physical therapy in patients with whiplash39 Härkäpää K, Järvikoski A, Vakkari T. Associations of locus ofcontrol beliefs with pain coping strategies and other pain-relatedcognitions in back pain patients. Br J Health Psychol1996;Feb:51-63.40 Vlaeyen JWS, Kole-Snijders AMJ, Rotteveel AM, Ruesink R, HeutsPHTG. The role of fear of movement/(re)injury in pain disability.J Occup Rehabil 1995;5:235-52.41 Van den Heuvel CMF, Vogels EMHM, Wams HWA. Verslag vanhet HOF-project. Handreikingen voor de communicatie tussenhuisarts en fysiotherapeut, oefentherapeut-Cesar en/ofoefentherapeut-Mensendieck. KNGF, LHV, NVOM and VBC.Amersfoort, the Netherlands: NPi; 1999.42 Whiplash Stichting Nederland. Beleid eerste opvangwhiplashpatiënten. Bunnik, the Netherlands: Whiplash StichtingNederland; 1999.43 Brouwer T, Nonhof-Boiten JC, Uilenreef-Tobi FC. Diagnostiek inde fysiotherapie. Proces en denkwijze. Utrecht, the Netherlands:Wetenschappelijke uitgeverij Bunge; 1995.44 Hendriks HJM, Oostendorp RAB, Bernards ATM, van RavensbergCD, Heerkens YF, Nelson RM. The diagnostic process andindication for physiotherapy. A prerequisite for treatment andoutcome evaluation. Phys Ther Rev 2000;5:26-47.45 Van Ravensberg CD, Oostendorp RAB, Heerkens YF. Diagnostiek,basis voor behandelplan en evaluatie. In: Vaes P, AufdemkampeG, den Dekker JB, van Ham I, Smits-Engelsman B, editors.Jaarboek Fysiotherapie/Kinesitherapie 1997. Houten/Diegem, theNetherlands: Bohn Stafleu Van Loghum; 1997.46 Oostendorp RAB, van Ravensberg CD, Wams HWA, Heerkens YF,Hendriks HJM. Fysiotherapie: Wat omvat het? Bijblijven1996;12:5-17, 39.47 Waterfield J, Sim J. Clinical assessment of pain by the visualanalogue scale. Br J Ther Rehabil 1996;3:94-8.48 Miller MD, Ferris DG. Measurements of subjective phenomena inprimary care research: the visual analogue scale. Fam Pract Res J1993;13:15-24.49 Vernon H, Mior S. The neck disability index: a study of reliabilityand validity. J Manipulative Physiol Ther 1991;14:409-15.50 Vernon H. The neck disability index: patient assessment andoutcome monitoring in whiplash. J Manipulative Physiol Ther1996;4:95-104.51 Stratford PW, Riddle DL, Binkley JM, Spadoni G, Westaway MD,Padfield B. Using the disability index to make decisionsconcerning individual patients. Physiother Can 1999;107-19.52 Lanser K. Cervicale segmentale instabiliteit. Ned Tijdschr ManTher 1988;7:82-4.53 Verhagen AP, Lanser K, de Bie RA, de Vet HC. Whiplash:assessing the validity of diagnostic tests in a cervical sensorydisturbance. J Manipulative Physiol Ther 1996;19:508-12.54 Brinkman DMC, Kuipers-Upmeijer J, Oosterhuis HJGH.Kwantificering en evaluatie van 5 neurologische evenwichtstestsbij proefpersonen en patiënten. Ned Tijdschr Geneeskd1996;140:2176-80.55 Bout J. Intra- en interbeoordelaarsbetrouwbaarheid vanevenwichtstests bij whiplashpatiënten (thesis). Brussels, Belgium:Vrije Universiteit Brussel, Faculteit Geneeskunde en FarmacieGGS Manuele Therapie; 1999.56 Kuipers-Upmeijer J, Oosterhuis HJGH. De proef van Unterbergerniet bruikbaar om de vestibulaire functie te testen. Ned TijdschrGeneeskd 1994;138:136-9.57 Peeters GGM, Verhagen AP, de Bie RA, Oostendorp RAB. Theefficacy of conservative treatment in patients with whiplashinjury: a systematic review of clinical trials. Spine2001;26(4):E64-73.58 Foley-Nolan D, Moore K, Codd M, Barry C, O’Connor P,Coughlan RJ. Low-energy high-frequency pulsed electromagnetictherapy for acute whiplash injuries. A double-blind randomisedcontrolled study. Scand J Rehab Med 1992;24:51-9.59 Provinciali L, Baroni M, Illuminati L, Ceravolo MG. Multimodaltreatment to prevent the late whiplash syndrome. Scand J RehabMed 1996;28:105-11.60 Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, HaraldsethO, Lereim I. Acute treatment of whiplash neck sprain injuries. Arandomized trial of treatment during the first 14 days after a caraccident. Spine 1998;23:25-31.61 Giebel GD, Edelman M, Hüser R. Die Distorsion derHalswirbelsäule: frühfunctionelle vs. ruhigstellende Behandlung.Zentralbl Chir 1997;122:517-21.62 McKinney LA. Early mobilisation and outcome in acute sprainsof the neck. Br Med J 1989;299:1006-8.63 Mealy K, Brennan H, Fenelon GCC. Early mobilisation of acutewhiplash injuries. Br Med J 1986;292:647-56.64 Gennis P, Miller L, Gallagher EJ, Giglio J, Nathanson N. Theeffect of soft cervical collars on persistent neck pain in patientswith whiplash injury. Acad Emerg Med 1996;3:568-73.65 Magee DJ, Oborn-Barrett E, Turner S, Fenning N. A systematicoverview of the effectiveness of physical therapy intervention onsoft tissue neck injury following trauma. Physiother Can2000;Spring:111-30.66 Foley-Nolan D, Barry C, Coughlan RJ, O’Connor P, Roden D.Pulsed high-frequency (27 MHz) electromagnetic therapy forpersistent neck pain. A double-blind, placebo-controlled study of20 patients. Orthopedics 1990;13:445-51.67 Rosenfeld M, Gunnarson R, Borenstein P. Early intervention inwhiplash-associated disorders. A comparison of two treatmentprotocols. Spine 2000;25:1782-7.68 Morley S, Eccleston C, Williams A. Systematic review and metaanalysisof randomized controlled trials of cognitive behaviourtherapy and behaviour therapy for chronic pain in adults,excluding headache. Pain 1999;80:1-13.69 Gross AR, Aker PD, Goldsmith CH, Peloso P. Conservativemanagement of mechanical neck disorders. Part 2: physicalmedicine modalities. The Cochrane Library; 1999;4.70 Gross AR, Aker PD, Goldsmith CH, Peloso P. Patient educationfor mechanical neck disorders. The Cochrane Library; 1999;4.71 Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Effects ofpulmonary rehabilitation on physiologic and psychosocialoutcomes in patients with chronic obstructive pulmonarydisease. Ann Intern Med 1995;122:823-32.72 Schouten JSAG, van der Linden SJ. Effecten van interventies bijartrose. 1998. Achtergrondstudie bij: Schouten JSAG, van derLinden SJ. Artrose van heup en knie. In: van der Meer J,Schouten JSAG, editors. Volksgezondheid Toekomstverkenning1997: Effecten van zorg. Maarssen, the Netherlands: Elsevier/DeTijdstroom; 1997.73 Van Tulder MW, Koes BW, Assendelft WJJ, Bouter LM. Theeffectiveness of conservative treatment of acute and chronic lowback pain. Amsterdam, the Netherlands: EMGO Institute; 1999.74 Hilde G, Bø K. Effect of exercise in the treatment of low backpain. A systematic review emphasising type and dose of exercise.Phys Ther Rev 1998;3:107-17.75 Nordin M. Education and return to work. In: Gunzburg R,Szpalski M, editors. Whiplash Injuries. Philadelphia: Lippincott-Raven; 1998:199-209.76 Van der Burgt M, Verhulst F. Doen en blijven doen.V-09/2003/US29

KNGF-guidelines for physical therapy in patients with whiplashPatiëntenvoorlichting in de paramedische praktijk.Houten/Diegem, the Netherlands: Bohn Stafleu Van Lochem;1996.77 Hoenen JAJH, Tielen LM, Willink AE. Patiëntenvoorlichting stapvoor stap: suggesties voor de huisarts voor de aanpak vanpatiëntenvoorlichting in het consult. Rijswijk, the Netherlands:Uitgeverij voor gezondheidsbevordering, Stichting O&O; 1988.78 Projectteam ‘whiplash-trial’. Behandelprotocol voorwhiplashpatiënten in relatie tot het gezondheidsprofiel.Amersfoort, the Netherlands: Nederlands Paramedisch Instituut;1999.79 Verhoeven ALJ, van der Heuvel CMF. KNGF-Richtlijn‘Informatieverstrekking huisarts’. Amersfoort, the Netherlands:KNGF; 1995.80 KNGF. Richtlijnen voor de fysiotherapeutische verslaglegging.1993. Amersfoort, the Netherlands; Koninklijk NederlandsGenootschap voor Fysiotherapie; 1993.30V-09/2003/US