Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Spine J. 2016 Dec;16(12):1541-1565. doi: 10.1016/j.spinee.2014.06.019. Epub 2014 Jul 8.


Background context: Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD).

Purpose: To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD.

Study design/setting: Systematic review and best-evidence synthesis.

Patient sample: We included randomized controlled trials (RCTs), cohort studies, and case-control studies.

Outcome measures: Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events.

Methods: We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles.

Results: We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD.

Conclusions: Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.

Keywords: Multimodal care; Neck pain and associated disorders; Outcome; Recovery; Systematic review; Whiplash-associated disorders.

Publication types

  • Evaluation Study
  • Meta-Analysis

MeSH terms

  • Combined Modality Therapy / methods*
  • Exercise Therapy / methods*
  • Humans
  • Neck Pain / etiology
  • Neck Pain / rehabilitation*
  • Neck Pain / therapy
  • Quality of Life
  • Randomized Controlled Trials as Topic
  • Systematic Reviews as Topic
  • Whiplash Injuries / complications
  • Whiplash Injuries / rehabilitation*
  • Whiplash Injuries / therapy