Before we start let’s clarify what we’ll be discussing here. This post relates solely to those individuals who you have identified as being at high risk of poor recovery, most probably within six weeks following the injury.
So we will not be discussing the evidence for the management of acute whiplash and we will not be discussing the evidence for the management of persistent whiplash either. I have covered clinical ways to identify individuals at risk of poor recovery here and here.
The individual this relates to will most likely have a few or all of the following:
- ongoing high levels of pain and disability
- post traumatic stress reaction
- clinically significant levels of catastrophisation
- neuropathic pain
- low expectations of recovery
So, the million dollar question is: what do we do now we have identified the at risk person? Here are three ways to manage this risk:
Triaging whiplash: the sooner the better
Firstly, many international studies (Ritchie and Sterling 2016) strongly suggest that most recovery from whiplash takes place in the first 3 months following the injury. What does this mean for us: simply that we must triage as early as possible (i.e. identify the ‘at risk’ person) to attempt to intervene during a period when ‘natural recovery’ is still taking place. BUT BUT BUT….
Early intensive treatment may be detrimental
There is some evidence that early intensive treatment may be detrimental with reference to whiplash injury generally (Ritchie and Sterling 2016). As a result we need to make sure that we are targeting only those modifiable factors related to risk of poor recovery and that the approaches we are using have some evidence to support their use and are proving effective with this particular individual.
Target modifiable risk factors
The most important factors to address appear to be post-traumatic stress symptoms, catastrophisation and low expectations of recovery.
Clearly you need to make a judgement with respect to your confidence and training in dealing with these psychological factors.
Relaxation training for a less severe stress response and interventions directed at modifying low expectations of recovery through education may be fruitful avenues to explore in the clinic. Recent work has highlighted the potential role of so-called ‘Stress Inoculation Training’ (SIT).
SIT is a cognitive behavioural approach that teaches various general problem solving and coping strategies to manage stress-related anxiety (i.e. relaxation training, cognitive restructuring, and positive self-statements) providing information to individuals about the impact of stress on both their physical and psychological health. This approach reflects – in part – contemporary approaches to low back pain e.g. cognitive functional therapy and pain neuroscience education.
Catastrophisation may also be modifiable through education, discussion and advice regarding helpful coping self-statements (‘my neck is healing up’, ‘I have a healthy neck’) and of course through movement based graded exposure interventions to decrease fear of movement and re injury.
So, a ‘psychologically informed physiotherapy’ in those people presenting with lower scores on the Pain Catastrophising Scale (PCS) and Impact of Event Scale (IES) may well be appropriate but higher scores on the IES (>25) (Sterling 2014) will definitely require referral to a Clinical Psychologist for cognitive behavioural therapy.
A recent study of CBT intervention in people with chronic whiplash and symptoms of a post-traumatic stress response led to decreased psychological symptoms and decreased pain-related disability (Dunne, Kenardy, Sterling 2012).
Finally, clinical evidence of neuropathic pain would suggest that a trial of neuropathic pain medication may be appropriate, although a recent trial in acute whiplash revealed poor tolerance of side effects (Jull et al 2013).
With reference to exercise and activity. This can be used in the treatment of the ‘at risk’ individual on condition that the outcome is monitored closely and treatment only continued if there is improvement, as effect sizes for these treatments are small (Sterling 2014) and it is likely that it is only a sub group that responds to this approach. There is no evidence for one specific exercise approach to be favoured over another.
Take home massages:
< 6 weeks post injury: keep an eye on pain (+/- neuropathic), disability, catastrophisation and expectations for recovery. Modify these through targeted interventions such as relaxation training, challenging beliefs about injury and fear of movement. Use exercise and activity to increase confidence and reduce fear of movement.
> 6 weeks post injury: screen for post traumatic stress response if you remain concerned. Do not screen prior to 6 weeks. Refer to psychologist if a post traumatic stress reaction is identified at this stage.
Keep treatment to a minimum.
Dunne RL, Kenardy J, Sterling M. A Randomized Controlled Trial of Cognitive-behavioral Therapy for the Treatment of PTSD in the Context of Chronic Whiplash. Clinical Journal of Pain 2012;28(9):755-65. 52
Foa, E. B., L. Cashman, L. Jaycox, and K. Perry. 1997. “The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale.” Psychological Assessment 9 (4):445-451. doi: 10.1037//1040-35184.108.40.2065.
Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling M. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain 2013;154(9):1798-806
Ritchie C Sterling S 2016 Recovery Pathways and Prognosis After Whiplash Injury J Orthop Sports Phys Ther 2016;46(10):851-861. Epub 3 Sep 2016 doi:10.2519/jospt.2016.6918
Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother 2014;60(1):5-12.