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									                                                                  ISPI News

March 2011

                                                                                                          South African Edition

                                                                                                                         this issue
                                                                                                                       Editorial          1
Research:                                                                                                              QTF                2
                                                                                                                       Whiplash          3
   WHIPLASH                                                                                                            Schedule           4

    UPDATE                      THE FEAR COMPONENT: A Patients Roadblock to Recovery
 Quebec Task Force on
  Whiplash 1995              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
 Review of the Literature
                             in oneself could cause a cascade of events, which would lead to
  on whiplash associated     negative consequences in the future. If fear remained in the minds of
  disorder management        the people, he said this would inhibit the ability to advance from their
                             current situation - a severe economic downturn. In this speech, FDR
 RCT’s from 2009 to cur-
                             was attempting to give confidence and provide leadership to the
                             American people, thus reducing their fear and allowing them to be
  rent on various physical
                             able to move forward toward a better future.
  therapy treatments for
  whiplash                   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 pro-
                             gressing 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 con-
                                                     tribute 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 them-
                                                     selves, 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
            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:                     Studies/Literature reviewed relating to whiplash disorders, i.e., Medline. Literature subjected to a two-stage screening process.
Inclusion criteria:          1980 – 1993; 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.
Process:                     2 Year period; 16 paired task force members; Accepted study: Both relevant and meritorious.
Results:                     Collected articles:                     10382
                             Eligible articles for screening:        1204
                             Studies for independent review:         294
                             Relevant & meritorious                   62 (21% of the 294 articles)
Collars:                     Commonly prescribed; May delay recovery: Increased pain, decrease R.O.M; Soft collars do not adequately immobilize the
Rest:                        Commonly prescribed for the first few days. Should be limited to less than 4 days; Detrimental to recovery from whiplash asso-
                             ciated disorders (WAD).
Cervical pillows:            No studies found.
Manipulation:                Single manipulation reduced asymmetry; lasted less than 48 hours. Manipulation versus mobilization: Same effect in decreas-
                             ing pain and increasing R.O.M. Long-term manipulation is not justified.
Mobilization:                Maitland and McKenzie mobilization vs. rest showed significantly greater improvement in pain and R.O.M. Patients given ac-
                             tive 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 benefi-
                             cial 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.
Traction:                    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
Posture:                     No studies
Spray and stretch:           No studies
TENS:                        No accepted studies
E-stim:                      No studies
Ultrasound:                  No studies
Laser, Diathermy, Heat, Ice, Massage: No independent studies; Were part of the combination of passive modalities in different studies.
Surgery:                     No studies on surgery or nerve blocks
 Epidural, intra-thecal:    No studies
 Intra-articular steroid:   "Not justified in the management of WAD”
Analgesics and NSAID’s       Shown to be effective with the use of modalities
Muscle relaxants:            No studies
Psychosocial:                No studies
Acupuncture:                 No studies

                                                         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."

                                                page 2
                                           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 dis-
     ability 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 fre-
     quency of analgesic consumption. The improvements were partly maintained at nine months.(Bunketorp, Lindh et al.
    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 symp-
       toms 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 nota-
       ble 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 physio-
       therapy 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 capa-
       bility 1 year after a whiplash injury.(Kongsted, Qerama et al. 2007)

                                                                    page 3
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 em-
      ployment. (Amirfeyz, Cook et al. 2009)
     Intensive therapy in late whiplash syndrome can achieve improvement of different outcome measures including working ability in two-
      thirds of patients, more effective in women, persisting beyond 6 months in half. Additional cognitive-behavioral therapy was the most ef-
      fective 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.
     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.
                   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 lit-
                    erature.(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 Provo-
cation 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): 973-7.
2.    Angst, F., G. Francoise, et al. (2010). "Interdisciplinary rehabilitation after whiplash injury: an observational prospective outcome study." J Rehabil Med 42(4): 350-6.
3.    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): 1799-807.
4.    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): 201-17.
5.    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): 215-23.
6.    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): 699-706.
7.    Hurwitz, E. L., E. J. Carragee, et al. (2009). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders." J Manipulat-
      ive Physiol Ther 32(2 Suppl): S141-75.
8.    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): 28-34.
9.    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): 618-26.
10.   Lundmark, H. and A. L. Persson (2006). "Physiotherapy and management in early whiplash-associated disorders (WAD) -- a review." Advances in Physiotherapy 8(3): 98-105.
11.   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): 1652-7.
12.   Pato, U., G. Di Stefano, et al. (2010). "Comparison of randomized treatments for late whiplash." Neurology 74(15): 1223-30.
13.   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): E64-73.
14.   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): 1799-804.
15.   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): 59-68.
17.   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): 295-304.
18.   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): 305-12.
19.   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): 313-
20.   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): CD003338.

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