62 Spinal manual therapy is commonly used in the clinical managem

62 Spinal manual therapy is commonly used in the clinical management of neck pain. It is difficult to tease out the effects of manual therapy alone because most studies have used it as part of a multimodal package of treatment. Systematic reviews of the few trials that have assessed manual therapy techniques alone conclude

that manual therapy applied to the cervical spine (passive mobilisation) may provide some benefit in reducing pain, but that the included trials were of low quality.49, 50 and 56 One low-quality trial found that manipulative thrust techniques to the thoracic spine added to multimodal physiotherapy treatment resulted in a greater reduction of pain than multimodal physiotherapy alone, but the effect was small (SMD −0.68, 95% CI Microbiology inhibitor −1.11 to −0.25).63 There have been no randomised controlled trials of spinal manual therapy alone for chronic WAD. In view of the current evidence, clinical guidelines advocate that manual therapy can

be used in conjunction with exercise and advice, if there is evidence of continued benefit via validated outcome measures.37 Whilst not traditionally a physiotherapy treatment, physiotherapists often recommend over-the-counter medications to patients or communicate with the patient’s general practitioner regarding the need for medication. For acute WAD, it would seem logical that, as with any acute injury or trauma, the provision of pain medication in the early stages would medroxyprogesterone be appropriate,64 particularly considering AZD2281 clinical trial that initial higher levels of pain are associated with poor recovery from whiplash injury and that features indicative of central hyperexcitability are common. Yet there have been very few trials of medication in acute WAD. One early study showed that intravenous infusion of methylprednisolone provided in a hospital emergency department for acute whiplash resulted in fewer sick days over 6 months and less pain-related disability than those who received placebo medication.65 Whilst this is an interesting

finding, it would not be feasible in primary care settings and may have potentially harmful effects.37 In a recent randomised controlled trial, little pain relief was obtained from muscle relaxants either alone or combined with non-steroidal anti-inflammatory drugs for emergency department patients with acute whiplash.66 There have also been few trials of medication for chronic WAD. This is in contrast to other conditions such as low back pain and fibromyalgia, the latter of which shows a similar sensory presentation to chronic WAD. Current clinical guidelines recommend, on consensus, that general pain management guidelines64 are followed for the provision of medication to patients with acute and chronic WAD37 until further evidence becomes available.

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