Whiplash and Physical Therapy LiaVelys SPT Ithaca College Physical Therapy August, 2012
Objectives • Classify WAD injuries • Identify prognostic implications • Use evidence based treatments
What is Whiplash? • An acceleration–deceleration mechanism of energy transfer to the neck resulting from rear-end or side-impact motor vehicle collisions, but also from diving or other mishaps. Does not include head trauma, loss of consciousness, or posttraumatic amnesia.
Whiplash Associated Disorders Quebec Task Force
Body Structure and Function • Muscles • Ligaments • Facets • Discs • Nerves • Fascia • Cartilage • Joint Capsules
Impairments • headache, blurred vision, tinnitus, vertigo, dizziness • chewing and swallowing problems • reduced coordination • Fatigue, reduced energy, psychologic dysfunction • depression, irritability, and sleep disorders • reduced ROM of the cervical spine • trigger points, and taut bands • myofascial tension of the scalene muscles causes a thoracic outlet syndrome • brachialgia
The need for more • NSAIDS and soft collars have been the treatment of choice after whiplash injury • 30-60% of people treated this way have pain at 6 months • Cost in the US is 3.9 billion per year Vassiliou
Prognosis • Depression, anxiety, stress • low level job satisfaction • pre existing degenerative changes, or headaches • High initial pain intensity • neurologic signs • Low weight of vehicle in comparison to other vehicle • poor headrest position • rear end collision while looking to the side
Hendricks et al. • Inception point: 2 weeks after injury • At one year 64% had recovered. Female, high intensity of pain, disability, and sleep difficulties predicted poor prognosis. • Correctly classified 89% of patients • Neck pain intensity and work disability were the strongest, most consistent prognostic indicators
Treatment in the acute stage • Soft collars are not recommended • Manual mobilization and soft tissue techniques should be considered to decrease pain, improve ROM, and improve function • *active exercise should be started within 4 days of injury • Education regarding relaxation techniques, self management, return to normal activities ASAP, coping strategies, origin of pain • TENS Moore et al
Vassiliouet al • Compared soft collar to active therapy and found a significant difference in pain intensity and disability at 6 weeks and 6 months but not at one week.
Schnabel et al • Exercise therapy had decreased HA, neck pain, shoulder pain, and improved recovery more than collars.
Subacute 2-12 weeks • Combined manipulation and manual mobilization • Muscle retraining • Multimodal program (posture, manual, psychological support) • Coping strategies, TENS, massage, soft tissue moore
Kinesiotape • Decreased pain immediately after application and at 24 hours as compared to sham group. Gonzalez-Iglesias
Rushton Review • Decreased pain, improved ROM, decreased disability favors active exercise over control.
Ask et al. • Used a “high risk group” (significant pain at 6 weeks) • Motor control training vs. strengthening • Results: both saw significant improvements at 6 weeks, however if exercises were not continued, participants returned close to baseline at 1 year post intervention.
Chronic Stage • Mobilization, manipulation • Coping strategies, exercise, group exercise, proprioceptive exercises, strengthening stretching, isometric, isotonic, extension/retraction • At this stage ultrasound, EMG biofeedback, thermotherapy, stim, TENS, massage cannot be supported or refuted moore
Pato et al. • Cognitive Behavioral Therapy: designed to teach control of pain by controlling the physical reactions to stress and pain through relaxation, stress reduction, and chronic pain management techniques • Patients were already in the chronic stage greater than 6 months of pain!! • Imagery, progressive muscle relaxation • After 8 weeks of treatment (physiotherapy or infiltration or medication) (with or without CBT) 2/3 of patients got better. No differences among the 3 treatment groups however, those that received CBT did better. CBT only effective in women • 6 months later 43% still felt improved, 13% recovered • 73% of women and 50% of men got better • Working ability improved overall (p 0.023) in the infiltration (p 0.016) and physiotherapy (p 0.035) groups but not in the medication group.
Outcome Measures • The NDI is a valid and reliable measure of pain and disability as a result of neck pain comprising 10 items relating to functional activities, pain intensity, concentration and headache. Six responses ranging from no disability (0) to total disability (5) are available for each item. Total scores (out of a possible 100) are calculated by summing the responses to each item and multiplying by 2 with higher scores indicating greater levels of pain and disability. • MCID=5 points
SECTION 8 – DRIVING • I can drive my car without neck pain. • I can drive as long as I want with slight neck pain. • I can drive as long as I want with moderate neck pain. • I can't drive as long as I want because of moderate • neck pain. • I can hardly drive at all because of severe neck pain. • I can't drive my car at all because of neck pain.
Research Woes • Systematic reviews have difficulty comparing studies due to the variety of WAD levels used, and differences in treatment programs • Lack of validating studies for prognostic factors
The big picture • Active exercise is proven to be more effective than passive interventions and should be implemented within the first week. • Encourage fitness program/HEP after discharge • Multimodal treatment plans should be used including CBT, exercise, mobilizations. • Interdisciplinary approach! Psych consult if necessary. • High initial pain intensity predicts poor outcome.
Where do we go from here? • Our professional duty to educate the public and physicians that it is best if we see these patients early instead of relying on medication and soft collars in order to reduce healthcare costs.
References • Schnabel M, Ferrari R, Vassiliou T, Kaluza G. Randomised, controlled outcome study of active mobilisation compared with collar therapy for whuplash injury. Emerg Med J. 2004;21:306-310. • Pato U, et al. Comparison of randomized treatments for late whiplash. Neurology. 2010;74:1223-1230. • Stewart MJ, et al. Randomized controlled trial of exercise for chronic whiplash-associated disorders. Pain. 2007:128:59-68. • Vassiliou T, et al. PhysialTtherapy and active exercises- An adequate treatment for prevention of late whiplash syndrome? Randomized controlled trial in 200 patients. Pain. 2006;124:69-76. • Ask T, Strand LI, Skouen JS. The effect of two exercise regimes; motor control versus endurances/strength training for patients with whiplash-associated disorders: a randomized controlled pilot study.clinRehabil. 2009;23:812-823.
Gonzalez-Iglesias et al. Short term effects of cervical kinesiotaping on pain and cervical range of motion in patients with acute whiplash injury: a randomized controlled trial. Journal of orthopedic and Sports Physical Therapy. 2009;39(7):515-521. • Rushton A, et al. Physiotherapy rehabilitation for whiplash associated disorder II: a systematic review and meta-analysis of randomzised controlled trials. BMJ Open. 2011;1:1-13. • Moore A, et al. Clinical guidelines for the physiotherapy management of whiplash associated disorder. 2005. • Hendrikes EJM, et al. Prognostic factors for poor recovery in acute whiplash patients. Pain. 2005;114:408-416.