Chronic whiplash-associated disorders: to exercise or not? (original) (raw)
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Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome?
Clinical Rheumatology, 2009
Chronic whiplash-associated disorders (WAD) remains a challenging condition for clinicians. There is substantial evidence for the presence of various cervical dysfunctions (e.g., increased cervical muscle tone and impaired cervical movement control), but their contribution to the complex clinical picture of subjects with chronic WAD seems rather limited. There is consistent evidence for increased responsiveness of the central nervous system in those with chronic WAD, and central pain processing is likely to play a crucial role in the transition from an acute whiplash trauma towards chronic WAD. The manuscript explains how our current understanding of chronic WAD can be used to steer the content of conservative interventions and how treatment of cervical dysfunctions in patients with chronic WAD should account for the processes involved in chronicity. It is recommended to prevent sensorimotor incongruence, target cognitive-emotional sen-sitization, and apply a cognitive behavioral therapy-guided exercise program.
BMC Musculoskeletal Disorders
Background: There is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls. Methods: Participants are a subgroup (n = 30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the "butterfly test" and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n = 30). Discussion: The study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD.
A review of the literature on whiplash associated disorders
RAND Europe was asked by the Swiss Insurance Association (SIA) to study what treatment strategies are appropriate in dealing with whiplash associated disorders (WAD), with a specific focus on prevention of long-term disability. The main objectives of the study are:
The late whiplash syndrome: a psychophysical study
European Journal of Pain, 2002
Some patients who have sustained whiplash injuries present with chronic widespread pain and mechanical allodynia. This single-blind, case control matched study of 43 chronic whiplash patients sought to examine psychophysical responses to non-noxious stimuli and their relationship to psychological profiles. Symptom Check List 90-R (SCL-90-R), Neck Disability Index and Shortform McGill Questionnaire were completed prior to testing. Qualitative stimuli comprised light touch, punctate pressure, moderate heat and cold. Additionally, sustained vibration was administered using a vibrameter which allowed ramping of either frequency or amplitude. Twenty-eight patients reported vibration-induced pain. No control subject experienced pain in response to vibration. No significant differences in perception threshold to vibration were noted between patients and control group. Twenty-three patients and ten control subjects reported painful responses to cold. Eleven patients and nine control subjects experienced pain in response to moderate heat. Four patients rated punctate pressure and one patient rated light touch as painful. SCL-90-R profiles revealed an overall elevated level of distress in the whiplash group. No significant difference was found between patients with and without vibration-induced pain for any dimension of the SCL-90-R. Pain in response to non-noxious stimulation over presumably healthy tissues suggests that central mechanisms are responsible for ongoing pain in at least some whiplash patients. The additional findings of pain on punctate pressure and hyperalgesic responses to heat and cold stimuli are consistent with enhanced central responsiveness to nociceptor input. These results have important therapeutic and prognostic implications. #
Journal of Rehabilitation Medicine, 2007
Background: Many patients with chronic whiplash-associated disorders have reduced neuromuscular control of the neck and head. It has been proposed that a new sling exercise therapy may promote neuromuscular control of the neck. Objectives: To compare the effects of traditional physiotherapy vs traditional physiotherapy combined with a new sling exercise therapy on discomfort and function in patients with chronic whiplash-associated disorders who have unsettled compensation claims; and to investigate possible additional effects of guided, long-term home training. Design: A randomized multi-centre trial with 4 parallel groups. Methods: A total of 214 patients were assigned randomly to 4 treatment groups, and received either traditional physiotherapy with or without home training, or new sling exercise therapy with or without home training. Outcome measures were pain, disability, psychological distress, sick leave and physical tests. Results: A total of 171 patients (80%) completed the study. There were no important statistical or clinical differences between the groups after 4 months of treatment. There was a small statistically significant effect at 12-month follow-up in both groups with home training regarding pain during rest (p = 0.05) and reported fatigue in the final week (p = 0.02). Conclusion: No statistically significant differences were found between the traditional physiotherapy group and the new sling exercise group, with or without home training. Since the groups were not compared with a control group without treatment, we cannot conclude that the studied treatments are effective for patients with whiplash-associated disorder, only that they did not differ in our study.
Randomized controlled trial of exercise for chronic whiplash-associated disorders
Pain, 2007
Whiplash-associated disorders are common and incur considerable expense in social and economic terms. There are no known effective treatments for those people whose pain and disability persist beyond 3 months. We conducted a randomized, assessor-blinded, controlled trial at two centres in Australia. All participants received 3 advice sessions. In addition the experimental group participated in 12 exercise sessions over 6 weeks. Primary outcomes were pain intensity, pain bothersomeness and function measured at 6 weeks and 12 months. Exercise and advice was more effective than advice alone at 6 weeks for all primary outcomes but not at 12 months. The effect of exercise on the 0–10 pain intensity scale was −1.1 (95%CI −1.8 to −0.3, p = 0.005) at 6 weeks and −0.2 (0.6 to −1.0, p = 0.59) at 12 months; on the bothersomeness scale the effect was −1.0 (−1.9 to −0.2, p = 0.003) at 6 weeks and 0.3 (−0.6 to 1.3, p = 0.48) at 12 months. The effect on function was 0.9 (0.3 to 1.6, p = 0.006) at 6 weeks and 0.6 (−0.1 to 1.4, p = 0.10) at 12 months. High levels of baseline pain intensity were associated with greater treatment effects at 6 weeks and high levels of baseline disability were associated with greater treatment effects at 12 months. 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.