ISPI News South African Edition

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1 I S S U E 03 M a r c h ISPI News South African Edition this issue Research: WHIPLASH TREATMENT UPDATE Quebec Task Force on Whiplash 1995 Review of the Literature on whiplash associated disorder management RCT s from 2009 to current on various physical therapy treatments for whiplash On March 4, 1933, Franklin D. Roosevelt spoke some very powerful words in his first inaugural address. He stated, the only thing we have to fear is fear itself. He understood that allowing fear to reside in oneself could cause a cascade of events, which would lead to negative consequences in the future. If fear remained in the minds of the people, he said this would inhibit the ability to advance from their current situation - a severe economic downturn. In this speech, FDR was attempting to give confidence and provide leadership to the American people, thus reducing their fear and allowing them to be able to move forward toward a better future. Editorial 1 QTF 2 Whiplash 3 Schedule 4 THE FEAR COMPONENT: A Patients Roadblock to Recovery Fear is defined as a distressing emotion aroused by a perceived threat. In the physical therapy setting, pain and dysfunction are threats to many of our patients, which in turn cause an increase in fear response. Patients will be afraid to move, begin avoidance behaviors, and develop compensatory patterns. These behaviors will cause challenges in the rehabilitative process. Research and clinical experience has shown that patients who have increased fear oftentimes do not respond as quickly to physical therapy and are at greater risk for progressing down a road of increased disability. Fear reduction can be an area that is frequently overlooked by physical therapists. At times, we focus on other deficits in our treatment and forget to address this area during physical therapy sessions. A patient not fully understanding their pain or pathology can contribute to increased fear of their condition. By spending just a few minutes with a patient addressing fears will pay huge dividends in the rehabilitation process. Education is the most effective way to address the fear component. Too many of our patients do not understand what is going on with them when they hurt or lose function. Many times they have been provided with poor information about their condition, which has contributed to their increased fear. Healthcare practitioners have used threatening language, internet sites provide threatening images, and failed prior treatments all contribute to a patients fear with an injury. After a thorough evaluation, inform the patient about what is wrong with them, how you are going to help, what they can do for themselves, and how long will it take. Education is therapy. Keep it simple: Reduction of Fear = Improved Therapy Outcomes. - Matt McCoy, PT, MPT, CSMT Education is Therapy

2 Whiplash Update - Where are we at? In 1995 the Quebec Task Force (Spitzer, Skovron et al. 1995) produced the Gold Standard of all reviews related to whiplash: Methods: Inclusion criteria: Process: Studies/Literature reviewed relating to whiplash disorders, i.e., Medline. Literature subjected to a two-stage screening process ; English/French; Acceleration-deceleration injury to neck from MVA; Exclusion criteria: Grade 0 (no disability) and Grade IV (fracture) not included; Additional notes up until July 1994 was added. 2 Year period; 16 paired task force members; Accepted study: Both relevant and meritorious. Results: Collected articles: Eligible articles for screening: 1204 Studies for independent review: 294 Relevant & meritorious 62 (21% of the 294 articles) Collars: Rest: Cervical pillows: Manipulation: Mobilization: Traction: Posture: Spray and stretch: TENS: E-stim: Ultrasound: Commonly prescribed; May delay recovery: Increased pain, decrease R.O.M; Soft collars do not adequately immobilize the spine Commonly prescribed for the first few days. Should be limited to less than 4 days; Detrimental to recovery from whiplash associated disorders (WAD). found. Single manipulation reduced asymmetry; lasted less than 48 hours. Manipulation versus mobilization: Same effect in decreasing pain and increasing R.O.M. Long-term manipulation is not justified. Maitland and McKenzie mobilization vs. rest showed significantly greater improvement in pain and R.O.M. Patients given active exercises and advice recovered just as well as the mobilized group. Another study showed that mobilization was more effective than a combination of analgesics and education in the decrease of pain and increase of R.O.M. Appear to be beneficial in the short term, but the long-term benefits needs to be established. Physical therapy should emphasize early return to usual activity and promote mobility. No independent effects of traction were found; One study tested different types of traction (static, intermittent, manual), but no significant difference were found on the different traction types No accepted studies Laser, Diathermy, Heat, Ice, Massage: No independent studies; Were part of the combination of passive modalities in different studies. Surgery: on surgery or nerve blocks Injections: Epidural, intra-thecal: Intra-articular steroid: "Not justified in the management of WAD Pharmacology: Analgesics and NSAID s Muscle relaxants: Psychosocial: Acupuncture: Shown to be effective with the use of modalities Task Force Conclusions NSAID's and analgesics, short term manipulation and mobilization by trained persons, and active exercises are useful in grade II, and Ill WAD, but prolonged use of soft collars, rest, or inactivity probably prolongs disability in WAD. "Interventions that promote activity such as mobilization, manipulation, and exercises in combination with analgesics or NSAI D's are effective on a time-limited basis." "The key message to the WAD patient is that pain is not harmful, is usually short-lived and is controllable." ISPInstitute.com page 2

3 What is the latest evidence? A quick review of the highest forms of evidence (systematic reviews and high-quality randomized controlled trials) published in the last 10 years: Education, especially early on very important: Educational videos (Brison, Hartling et al. 2005; Oliveira, Gevirtz et al. 2006; Hurwitz, Carragee et al. 2009) Education helpful early on (Lundmark and Persson 2006) Movement exercise, manual therapy and act as usual Mobilization (Hurwitz, Carragee et al. 2009) Exercise (Hurwitz, Carragee et al. 2009) Moderate evidence postural exercise for decreasing pain and time off work(drescher, Hardy et al. 2008) In the short-term exercise and advice is slightly more effective than advice alone for people with persisting pain and disability following whiplash. Exercise is more effective for subjects with higher baseline pain and disability.(stewart, Maher et al. 2007) For patients exposed to whiplash trauma in a motor vehicle collision, an active involvement and intervention were both less costly and more effective than a standard intervention.(rosenfeld, Seferiadis et al. 2006) Supervised training was significantly more favorable than home training, with a more rapid improvement in self-efficacy, fear of movement/(re)injury and pain disability at three months. Further, supervised training significantly reduced the frequency of analgesic consumption. The improvements were partly maintained at nine months.(bunketorp, Lindh et al. 2006) Active/movement is helpful(peeters, Verhagen et al. 2001) Limited evidence Usual care (Hurwitz, Carragee et al. 2009) Physical modalities (Hurwitz, Carragee et al. 2009) Conflicting if stabilization exercises help (Drescher, Hardy et al. 2008) The current literature is of poor methodological quality and is insufficiently homogeneous to allow the pooling of results. Therefore, clearly effective treatments are not supported at this time for the treatment of acute, sub-acute or chronic symptoms of whiplash-associated disorders. Cochrane 2007: (Verhagen, Scholten-Peeters et al. 2007) Soft collar not helpful (Lundmark and Persson 2006) An evidence-based educational pamphlet provided to patients at discharge from the emergency department is no more effective than usual care for patients with grade 1 or 2 whiplash-associated disorder (Ferrari, Rowe et al. 2005) Patients with chronic whiplash associated disorders present with varied sensory, motor and psychological features. In this first instance it was questioned whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome. A randomized controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question. Participants were randomly allocated to receive either a multimodal physiotherapy program (MPT) or a self-management program (SMP) (advice and exercise).relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia. Further research is required to test the validity of this sub-group observation and to test the effect of the intervention in the long term. (Jull, Sterling et al. 2007) Immobilization, 'act-as-usual,' and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after a whiplash injury.(kongsted, Qerama et al. 2007) ISPInstitute.com page 3

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6 Education is Therapy What s new in whiplash management (2009 current)? There are literally hundreds of articles published annually on whiplash covering various psychological, neurological, trauma, and behavioral, etc. issues. A quick review of 2009 current regarding management of whiplash injuries reveals: Physical therapy is effective in the treatment of whiplash injury, especially in order to get the patients fit to go back to their previous employment. (Amirfeyz, Cook et al. 2009) Intensive therapy in late whiplash syndrome can achieve improvement of different outcome measures including working ability in twothirds of patients, more effective in women, persisting beyond 6 months in half. Additional cognitive-behavioral therapy was the most effective treatment modality. Classification of evidence: This interventional study provides Class III evidence that CBT used as an adjunct to infiltration, medication, or physiotherapy increases improvement rates in persons with late whiplash syndrome.(pato, Di Stefano et al. 2010) The rehabilitation program (drug adaptation, graded activity exercise, relaxation therapies, and behavioral therapy) showed moderate to large mid-term improvements in important health dimensions, medication reduction and working capacity. Further controlled studies are required to quantify and attribute these improvements more precisely.(angst, Francoise et al. 2010) A systematic review was conducted to evaluate the strength of evidence associated with various WAD therapies. Based on current evidence, activation-based therapy is recommended for the treatment of acute WAD; however, additional research is required to determine the relative effectiveness of various exercise-mobilization programs.(teasell, McClure et al. 2010) Although some evidence was identified to support the use of interdisciplinary interventions and manipulation, the evidence was not strong for any of the evaluated treatments. There is a clear need for further research to evaluate interventions aimed at treating patients with subacute WAD because there are currently no interventions satisfactorily supported by the research literature.(teasell, McClure et al. 2010) Based on the available research, exercise programs were the most effective noninvasive treatment for patients with chronic WAD, although many questions remain regarding the relative effectiveness of various exercise regimens.(teasell, McClure et al. 2010) Neurobiology education: Results showed a significant decrease in kinesiophobia (Tampa Scale for Kinesiophobia), the passive coping strategy of resting (Pain Coping Inventory), self-rated disability (Neck Disability Index), and photophobia (WAD Symptom List). At the same time, significantly increased pain pressure thresholds and improved pain-free movement performance (visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test) were established. Although the current results need to be verified in a randomized, controlled trial, they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD.(Van Oosterwijck, Nijs et al. 2011) Whiplash References 1. Amirfeyz, R., J. Cook, et al. (2009). "The role of physiotherapy in the treatment of whiplash associated disorders: a prospective study." Arch Orthop Trauma Surg 129(7): Angst, F., G. Francoise, et al. (2010). "Interdisciplinary rehabilitation after whiplash injury: an observational prospective outcome study." J Rehabil Med 42(4): Brison, R. J., L. Hartling, et al. (2005). "A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions." Spine 30 (16): Bunketorp, L., M. Lindh, et al. (2006). "The effectiveness of a supervised physical training model tailored to the individual needs of patients with whiplash-associated disorders--a randomized controlled trial." Clin Rehabil 20(3): Drescher, K., S. Hardy, et al. (2008). "Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review." Physiother Can 60(3): Ferrari, R., B. H. Rowe, et al. (2005). "Simple educational intervention to improve the recovery from acute whiplash: results of a randomized, controlled trial." Acad Emerg Med 12(8): Hurwitz, E. L., E. J. Carragee, et al. (2009). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders." J Manipulative Physiol Ther 32(2 Suppl): S Jull, G., M. Sterling, et al. (2007). "Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?--a preliminary RCT." Pain 129(1-2): Kongsted, A., E. Qerama, et al. (2007). "Neck collar, "act-as-usual" or active mobilization for whiplash injury? A randomized parallel-group trial." Spine 32(6): Lundmark, H. and A. L. Persson (2006). "Physiotherapy and management in early whiplash-associated disorders (WAD) -- a review." Advances in Physiotherapy 8(3): Oliveira, A., R. Gevirtz, et al. (2006). "A psycho-educational video used in the emergency department provides effective treatment for whiplash injuries." Spine 31(15): Pato, U., G. Di Stefano, et al. (2010). "Comparison of randomized treatments for late whiplash." Neurology 74(15): Peeters, G. G., A. P. Verhagen, et al. (2001). "The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials." Spine (Phila Pa 1976) 26(4): E Rosenfeld, M., A. Seferiadis, et al. (2006). "Active involvement and intervention in patients exposed to whiplash trauma in automobile crashes reduces costs: a randomized, controlled clinical trial and health economic evaluation." Spine (Phila Pa 1976) 31(16): Spitzer, W. O., M. L. Skovron, et al. (1995). "Scientific monograph of the Quebec task force on whiplash associated disorders : redefining whiplash and its management." Spine 20(Suppl): 10s-73s. 16. Stewart, M. J., C. G. Maher, et al. (2007). "Randomized controlled trial of exercise for chronic whiplash-associated disorders." Pain 128(1-2): Teasell, R. W., J. A. McClure, et al. (2010). "A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2 - interventions for acute WAD." Pain Res Manag 15(5): Teasell, R. W., J. A. McClure, et al. (2010). "A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 3 - interventions for subacute WAD." Pain Res Manag 15(5): Teasell, R. W., J. A. McClure, et al. (2010). "A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD." Pain Res Manag 15(5): Van Oosterwijck, J., J. Nijs, et al. (2011). "Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study." J Rehabil Res Dev 48(1): EPub ahead of print 21. Verhagen, A. P., G. G. Scholten-Peeters, et al. (2007). "Conservative treatments for whiplash." Cochrane Database Syst Rev(2): CD ISPInstitute.com page 6