the management of whiplash injuries that embodies critical contributory fac-tors to recovery such as the “pain experi-ence” and the chronicity of injuries. GDC Findings and Recommendations: Acute Phase WAD Cases: The literature provided sufficient evidence to establish that acute WAD patients may benefit from a combination of the following mo-dalities: early mobilization, education/ instruction, unsupervised and supervised cervical ROM exercises with multimodal treatment regimens. 6,7,8,9 The GDC rec-ommends a balanced passive and active care approach as well as encouraging the patient to resume normal daily activities at the earliest interval. Evidence does not support the use of collars or immobiliz-ing devices to improve health outcomes in this (or any) phase of the WAD injury. Sub-acute Phase WAD Cases: The lit-erature suggests in this stage the patient may benefit from multiple modalities including: posture instruction, mobiliza-tion, massage and cervical ROM exercise. Treatment that is less complex and less costly is recommended as well as the treatment that is least likely to contribute toward a propensity for chronic WAD. The exercise protocols varied greatly in the literature and should be prescribed based on clinical experience and the patient’s own specific situation. 10,11 The GDC stated that further investigation is required to evaluate the effects of treat-ment in sub-acute WAD cases. The GDC additionally advised that the practitioner should use a balanced approach of ac-tive and passive therapy, but it should become increasingly more active during this phase of care. Chronic Phase WAD Cases: Health outcomes in this phase were expanded to include not only pain perception and cer-vical ROM improvement, but addition-ally: posture, perceived disability, coping resources and life satisfaction. 12,13,14,15,16 Best evidence suggests that in this stage a combination of unsupervised and su-pervised exercise, and cognitive behav-ioural therapy, should be incorporated. Active intervention and independence is encouraged in this phase. The evidence suggests that health outcomes of a chron-ic WAD are more likely to improve if the patient is actively involved in the care. Active intervention is characterized by active involvement and responsibility by 34 • CaNaDIaN CHIROPRaCTOR | DECEMBER 2010 both the practitioner and patient (i.e., in-dependent exercise, self-directed appli-cations of cryotherapy, portable TENS/ IFC units, etc.) can maximize health out-comes. The GDC consensus is to balance active and passive care (as discussed in the earlier phases) in relation to the pa-tient’s clinical presentation. ception of pain, self-perceived dis-ability, the meaning of their symp-toms and how to best manage them are pertinent factors in the recovery process. 20 Pain perception can vary depending on gender, belief in the effectiveness of treatment, strong emotional states, cultural, family E ff o r t s a r e r e q u i r e d t o i m p r o v e t h e r i g o u r a n d q u a l i t y o f s t u d i e s e v a l u a t i n g t h e e ff e c t o f c h i r o p r a c t i c t r e a t m e n t i n WA D c a s e s GDC Recommendations for Improving the Literature: In general, the GDC advocates that efforts are required to improve the rigour and quality of studies evaluating the effect of chiropractic treatment in WAD cases. It was suggested that the WAD-Plus Model might enhance the comparison of stud-ies relevant to advancing chiropractic management of WAD. Gaps in current evidence on WAD intervention acknowl-edge that their review does not provide a comprehensive review of all chiroprac-tic treatment modalities and techniques. Future WAD research should also utilize “active comparators,” non-treatment and/or placebo groups to enhance evi-dence-based research on WAD outcomes and patient management. 17,18 and work factors. 20,21,22,23 The GDC deemed the following evaluative measures were helpful in quantify-ing psychosocial pain and the need for multidisciplinary care: Bour-nemouth Questionnaire, McGill Pain Questionnaire, Self-Efficacy Scale and Pain Catastrophizing Scale. The GDC recommends if the individual has a high degree of psy-chosocial pain, the focus should be on multidisciplinary management of behavioural components outside of chiropractic care. Chronicity Factors: The GDC rec-ommended that the practitioner should carefully consider the fol-lowing criteria for potential chro-nicity factors (1): socioeconom-ic factors; psychosocial factors, prior health status, symptom se-verity, compensation and legal fac-tors, health behaviours, attitudes and interventions contemplated. The GDC recommends that all four dimensions of the WAD-Plus Mod-el should be considered as part of WAD care. 3. WAD-PLUS MODEL The GDC put forth the WAD-Plus Model to advance the management of Whip-lash Associated Disorders and improve consistency and clinical management. The model refers to the assessment and defining of a WAD injury using conven-tional methods (i.e., the standard WAD 1, WAD 2, WAD 3, and WAD 4 defini-tions). Plus, three additional important dimensions relevant for client care: 1. The Time Since Injury: Generally accepted stages of soft tissue injury are classified into the inflammation, repair and remodelling stages. 19 The GDC consensus is that the practitio-ner should identify the individual’s phase of healing prior to starting care – as treatment intervention may vary depending on which stage of healing they are in. 2. The Pain Experience: This embodies psychosocial features of injury and pain experience. Individual’s per-CONCLUSIONS AND PRACTICAL APPLICATION • The development of guidelines aims to improve the assessment of WAD grades prior to beginning treatment. This guide is available to all practi-tioners through the Canadian Chi-ropractic Association’s website (see additional readings). • The WAD-Plus Model was devel-oped to identify the clinical mus-culoskeletal signs and symptoms described in the original WAD Continued on Page 38 www.canadianchiropractor.ca
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