Longstanding Whiplash Symptoms

Roughly one in 1,000 Australians will receive a whiplash diagnosis. Studies find that patients with acute neck pain develop chronic symptoms in 15% to 48% of cases.^1,2 The health care community is still searching for methods to improve outcomes and reduce societal costs related to whiplash-associated disorders (WAD). Bear in mind that a significant portion of the costs created by whiplash-associated disorders stems from sick leave and loss of productive capacity,³ and roughly 50% of patients with chronic WAD experience symptoms severe enough to interfere with daily life.⁴ It has been established that for new cases of WAD, cases managed without physiotherapy cost 220% more than cases managed with physiotherapy (when sick leave is included); that physiotherapy increases the likelihood of file closure at one year by 50%; and that best results are achieved when physiotherapy begins within 96 hours of the whiplash injury.^5-8 However, clinicians are not always in the position of treating neck injury patients within days of the injury. What about the patients who present with longstanding WAD?Roughly one in 1,000 Australians will receive a 

There does not appear to be consensus regarding the multi-factorial mechanisms underlying long-term WAD. However, we do know that individuals with more severe, chronic symptoms exhibit fatty infiltration in the multifidus muscle, altered neck muscle behavior, and decreased muscle function.^9-11 These alterations suggest a role for exercise therapy in modifying the persistence of WAD symptoms.

Recommendations include advice to remain active and the offering of some form of exercise,^12-14 but there is not a clear consensus on the best exercise protocol or which cases are likely to respond to physiotherapy.^13-15 Research suggests that patient education on self-directed exercise is unlikely to produce a clinically-significant effect,^16-18 but studies of supervised exercise therapy interventions are diverse. They often are uncontrolled or compare two treatment protocols, instead of comparing to wait list or placebo, making it difficult to form conclusions on what protocols are effective.

Fortunately, Anneli Peolsson and colleagues published a wait-list controlled, randomised prospective trial earlier this year to help answer this question.¹⁵ They randomised 60 patients to a wait list group or a group to receive a physiotherapy program of neck-specific exercises. Patients experienced WAD symptoms between six months and three years (mean one-year and 10 months), after a grade 2 or 3 whiplash injury. After three months of physiotherapy twice per week, the physiotherapy group reported significantly greater improvement in the Neck Disability Index, the Self-Efficacy Scale, and in a quality of life scale. While patients receiving physiotherapy improved their condition, the wait list group tended to get worse. For neck pain, the physiotherapy group trended 41% better than baseline on a visual analog scale.

The neck exercise program first focused on activity of the deep neck muscles and motor control. It progressed to gradually increasing resistance exercises focused on neck muscle endurance. When patients present to your practice with long-standing neck pain, please tell them that lasting relief and greater self-efficacy may be available through physiotherapist training in specific exercise therapies.

 

References

1. Pastakia K, Kumar S. Acute whiplash associated disorders (WAD). Open Access Emergency Medicine. 2011; 3: 29-32.
2. Schofferman J, Bogduk N, Slosar P. Chronic whiplash and whiplash associated disorders: an evidence-based approach. J Am Acad Orthop Surg. October 2007; 15 (10): 596-606.
3. Teasell R, McClure J, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 5 - Surgical and injection-based interventions for chronic WAD. Journal of Canadian Pain Society. 2010; 15 (5): 323.
4. Leth-Petersen S, Rotger G. Long-term labour-market performance of whiplash claimants. J Health Econ. 2009; 28: 996-1011.
5. Lamb S, Gates S, Williams M, et al. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. The Lancet. February 2013; 381 (9866): 546-556.
6. Suissa S, Girousx M, Gervais M, et al. Assessing a whiplash management model: a population-based non-randomized intervention study. J Rheumatol. 2006; 33: 581-7.
7. Rosenfeld M, Seferiadis A, Gunnarsson R. Active involvement and intervention in patients exposed to whiplash trauma in automobile pressures reduces costs. A randomised controlled clinical trial and health economic evaluation. Spine. 2006; 31: 1799-1804.
8. Rosenfeld M, Seferiadis A, Carlsson U, et al. Active intervention in patients with whiplash associated disorders improves long term prognosis. A randomised controlled clinical trial. Spine. 2003; 28: 2491-2498.
9. O’Leary S, Fall D, Jull G. The relationship between superficial muscle activity during the cranio-cervical flexion test and clinical features in patients with chronic neck pain. Man Ther. 2011; 16: 452-455.
10. Jull G, Kristjansson E, DallAlba P. Impairments in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther. 2004; 9: 89-94.
11. Elliott J, Pedler A, Kenardy J, et al. The temporal development of fatty infiltrates in the neck muscles following whiplash injury: an association with pain and posttraumatic stress. PLoS One. 2009; 6: e21194.
12. The Whiplash Commission Final Report. Sandviken;  2005, ISBN 91-975655-4-7.
13. Teasell R, McClure J, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD. Pain Res Manag. 2010: 15: 313-322.
14. Southerst D, Nordin M, Cote P, et al. Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. The Spine Journal. 2014; Feb 15. j.spinee.2014.02.014.
15. Peolsson A, Ludvigsson M, Tigerfors A, Peterson G. Effects of neck-specific exercises compared to waiting list for individuals with chronic whiplash-associated disorders: a prospective, randomized controlled study.  Archives of Physical Medicine and Rehabilitation. 2016; 97 (2): 189-195.
16. Lamb S, Gates S, Williams M, et al. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. The Lancet. February 2013; 381 (9866): 546-556.
17. Teasell R, McClure J, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 5 - Surgical and injection-based interventions for chronic WAD. Journal of Canadian Pain Society. 2010; 15 (5): 323.
18. Haines T, Gross A, Burnie S, et la. Cochrane review of patient education for neck pain. The Spine Journal. 2009; 9:859-71.