A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) - choosing the most efficient and cost-effective treatment: study protocol of a randomized controlled trial

Effectiveness of psychological interventions delivered by physiotherapists in the management of neck pain: a systematic review with meta-analysis

Physiotherapists are increasingly using psychological treatments for musculoskeletal conditions. We assessed the effects of physiotherapist-delivered psychological interventions on pain, disability, and quality of life in neck pain. We evaluated quality of intervention reporting. We searched databases for randomized controlled trials (RCTs) comprising individuals with acute or chronic whiplash-associated disorder (WAD) or nontraumatic neck pain (NTNP), comparing physiotherapist-delivered psychological interventions to standard care or no treatment. Data were extracted regarding study characteristics and outcomes. Standardised mean difference (SMD) was calculated by random-effects meta-analysis. We evaluated certainty of evidence using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) and intervention reporting using TIDieR. Fourteen RCTs (18 articles-4 detail additional outcome/follow-up data) were included comprising 2028 patients, examining acute WAD (n = 4), subacute/mixed NTNP (n = 3), chronic WAD (n = 2), and chronic NTNP (n = 5). Treatment effects on pain favoured psychological interventions in chronic NTNP at short-term (SMD -0.40 [95% CI -0.73, -0.07]), medium-term (SMD -0.29 [95% CI -0.57, 0.00]), and long-term (SMD -0.32 [95% CI -0.60, -0.05]) follow-up. For disability, effects favoured psychological interventions in acute WAD at short-term follow-up (SMD -0.39 [95% CI -0.72, -0.07]) and chronic NTNP at short-term (SMD -0.53 [95% CI -0.91, -0.15]), medium-term (SMD -0.49 [95% CI -0.77, -0.21]), and long-term (SMD -0.60 [95% CI -0.94, -0.26]) follow-up. GRADE ratings were typically moderate, and intervention reporting often lacked provision of trial materials and procedural descriptions. Psychological interventions delivered by physiotherapists were more effective than standard physiotherapy for chronic NTNP (small-to-medium effects) and, in the short term, acute WAD.

Evaluation of a Web-Based Stress Management Application-a Feasibility Study

The aim of the current study was to investigate the feasibility of a Web-based program that promotes behavior change for stress-related problems in terms of the program’s acceptability, practicability, and any possible effects. In addition, the aim was also to study how appropriate and realistic the study’s process and resource management would be for conducting a randomized controlled trial. A convenience sample consisting of 14 individuals was recruited from a university in Sweden. The participants had access to the program for a duration of 9 weeks. Questionnaires were answered before accessing, during use of, and after completing the program. Both qualitative and quantitative data were collected and analyzed. The program was considered acceptable and practically feasible, though small adjustments have to be made. The program was considered time-consuming, extensive, and in need of some clarifications. Regarding process and resource management, the study participants required minimum support. It was difficult to identify the time point when to send out the process measures because the participants worked at their own pace. Also, one of the process measurements, the motivation to change, remained stable. With some adjustments to the instructions to the study participants and minor changes in the program, the intervention and study’s procedure were considered as feasible and can be carried out in a randomized controlled trial.

What is the comparative effectiveness of current standard treatment, against an individually tailored behavioural programme delivered either on the Internet or face-to-face for people with acute whiplash associated disorder? A randomized controlled trial

Objective:

To investigate the comparative effectiveness of current standard treatment, against an individually tailored behavioural programme delivered via the Internet or face-to-face for people with acute whiplash associated disorders.

Design:

A multicentre, randomized, three-group design, with concealed allocation.

Subjects and settings:

A total of 55 participants (37 female), age 18–65, with acute Whiplash Associated Disorder (Grade I–II), recruited at two emergency clinics in Sweden.

Interventions:

Before randomization all participants received standard self-care instructions. The Internet and face-to-face groups followed a seven-week behavioural programme involving individual tailoring, via email (Internet group), or in sessions at a physical therapy unit (face-to-face group). The control group only received the self-care instructions.

Main measures:

Pain-related disability, pain intensity, self-efficacy in daily activities, catastrophizing and fear of movement/(re)injury. Assessments were performed at baseline (2–4 weeks postinjury) and at three, six and 12 months postintervention.

Results:

Both the Internet ( n = 16) and face-to-face ( n = 14) group showed a larger decrease in pain-related disability than the control group ( n = 16); −12 and −11, respectively, compared with −5 in the control group at 12-months follow-up. Significant differences between the groups in overall treatment effect were shown in all outcomes except pain intensity. All groups improved significantly over time in all outcomes, except for fear of movement/(re)injury and catastrophizing in the control group.

Conclusion:

An individually tailored behavioural programme improved biopsychosocial factors in patients with whiplash associated disorders up to 12 months after treatment. Internet-delivered intervention was as effective as clinic-based face-to-face therapy sessions.

Coping patterns and their relation to daily activity, worries, depressed mood, and pain intensity in acute whiplash-associated disorders

BACKGROUND

There is a lack of knowledge regarding how individuals with acute whiplash-associated disorders (WAD) appraise and cope with situation-specific stressors.

PURPOSE

The aim of the study was to describe the daily process of coping reported in a daily coping assessment by individuals with acute WAD within 1 month after the accident. More specifically, profiles of coping strategies were identified and patterns between stressors, primary and secondary appraisals, and coping strategy profiles were described in relation to reported level of activity, worries, depressed mood and pain intensity during the day.

METHOD

A descriptive and exploratory design was applied. Two hundred and twenty-nine whiplash-associated disorders-daily coping assessment (WAD-DCA) collected during seven consecutive days from 51 participants with acute WAD in Sweden, were included. Cluster analysis was used to obtain coping strategy profiles and data were graphically visualised as patterns through the coping process.

RESULTS

When measuring coping as a daily process relating to the specific stressful situation, different coping process patterns appeared. During days with a high degree of physical and mental well-being, high self-efficacy beliefs seemed to be working as an important secondary appraisal, whereas during days with a low degree of physical and mental well-being primary appraisals of the stressor as a threat and catastrophic thoughts were present in the coping process.

CONCLUSIONS

Early identification of situational- and individual-specific stressors, appraisals and coping efforts as measured by the WAD-DCA may contribute to the understanding of the coping process in the acute stage of WAD and its possible impact on recovery and adjustment.

The clinical course over the first year of whiplash associated disorders (WAD): pain-related disability predicts outcome in a mildly affected sample

Background

Different recovery patterns are reported for those befallen a whip-lash injury, but little is known about the variability within subgroups. The aims were (1) to compare a self-selected mildly affected sample (MILD) with a self-selected moderately to severely affected sample (MOD/SEV) with regard to background characteristics and pain-related disability, pain intensity, functional self-efficacy, fear of movement/(re)injury, pain catastrophising, post-traumatic stress symptoms in the acute stage (at baseline), (2) to study the development over the first year after the accident for the above listed clinical variables in the MILD sample, and (3) to study the validity of a prediction model including baseline levels of clinical variables on pain-related disability one year after baseline assessments.

Methods

The study had a prospective and correlative design. Ninety-eight participants were consecutively selected. Inclusion criteria; age 18 to 65 years, WAD grade I-II, Swedish language skills, and subjective report of not being in need of treatment due to mild symptoms. A multivariate linear regression model was applied for the prediction analysis.

Results

The MILD sample was less affected in all study variables compared to the MOD/SEV sample. Pain-related disability, pain catastrophising, and post-traumatic stress symptoms decreased over the first year after the accident, whereas functional self-efficacy and fear of movement/(re)injury increased. Pain intensity was stable. Pain-related disability at baseline emerged as the only statistically significant predictor of pain-related disability one year after the accident (Adj r² = 0.67).

Conclusion

A good prognosis over the first year is expected for the majority of individuals with WAD grade I or II who decline treatment due to mild symptoms. The prediction model was not valid in the MILD sample except for the contribution of pain-related disability. An implication is that early observations of individuals with elevated levels of pain-related disability are warranted, although they may decline treatment.

Health, social, and economic consequences of neck injuries: a controlled national study evaluating societal effects on patients and their partners

STUDY DESIGN

National register-based matched case-control study.

OBJECTIVE

The aim of this study was to estimate the direct and indirect costs of neck injuries, except fractures, in a national sample of patients and their spouses.

SUMMARY OF BACKGROUND DATA

Despite neck injuries causing significant socioeconomic burdens, there is insufficient information about the time course, as well as the effect on their spouses.

METHODS

Using records from the Danish National Patient Registry 1998-2009, all patients with a diagnosis of neck injury and their spouses were identified and compared with randomly chosen controls matched for age, sex, geographical area, and civil status. Direct costs included frequency of primary and hospital sector contacts and procedures and medication. Indirect costs included the effect on labor supply. Social transfer payments were included to illustrate the effect on national accounts. All cost data were extracted from national databases.

RESULTS

The register contributed 94,224 patients, and 372,341 matched controls were identified. The percentages of married or cohabiting individuals were approximately 47.5% in both groups. Patients with neck injury had significantly higher rates of health-related contacts, medication use, and higher socioeconomic costs than controls. To a lesser extent, they also had lower employment rates, and those employed generally had lower incomes. Furthermore, the patients had already presented negative social- and health-related status up to 11 years before the first diagnosis, which became more pronounced for those with the highest costs. The health effects on costs were present regardless of age group and sex, and it was also seen for the patients' spouses.

CONCLUSION

Neck injuries are associated with major socioeconomic consequences for patients, their spouses, and the society. However, the increased expenses during subsequent years cannot be explained by the injury alone, because these patients already had elevated expenses prior to the injury. This indicates some selection of increased vulnerability for both patients and their spouses.

Daily stressors in patients with acute whiplash associated disorders

PURPOSE

Stressors in acute whiplash associated disorders (WAD), as reported on a daily basis, have hitherto been neglected in research. The primary aim of this study was to describe the most stressful daily situation or event reported by individuals with acute WAD within a month of a whiplash trauma. Another aim was to describe the meaning and significance of these daily stressors, i.e. primary appraisal.

METHOD

A descriptive design with a content analysis approach was used. 260 WAD-daily coping assessments (WAD-DCA) generated during 1 week by 51 participants with acute WAD were included in the study. Stressors were analysed using qualitative content analysis.

RESULTS

The reported stressors generated 13 categories covering a wide range of stressful situations in daily life related to (i) work, (ii) physical symptoms, (iii) feelings and cognitions, (iv) family and home responsibilities and (v) recreation. The majority of the stressors were appraised as "expected" as well as "disabling". Most threatening stressors were related to work, driving and feelings/cognitions.

CONCLUSIONS

The wide variety of stressors indicates that it is not only pain itself that influences daily life in acute WAD. Early identification of individual and situation-specific stressors gives new data regarding what bothers individuals suffering from WAD after a collision and may be helpful in understanding the coping process in relation to specific stressors and stressor appraisals.

Patient education for neck pain

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear.

OBJECTIVES

To assess the short- to long-term effects of therapeutic patient education (TPE) strategies on pain, function, disability, quality of life, global perceived effect, patient satisfaction, knowledge transfer, or behaviour change in adults with neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache.

SEARCH METHODS

We searched computerised bibliographic databases (inception to 11 July 2010).

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCT) investigating the effectiveness of TPE for acute to chronic neck pain.

DATA COLLECTION AND ANALYSIS

Paired independent review authors conducted selection, data abstraction, and 'Risk of bias' assessment. We calculated risk ratio (RR) and standardised mean differences (SMD). Heterogeneity was assessed; no studies were pooled.

MAIN RESULTS

Of the 15 selected trials, three were rated low risk of bias. Three TPE themes emerged.Advice focusing on activation: There is moderate quality evidence (one trial, 348 participants) that an educational video of advice focusing on activation was more beneficial for acute whiplash-related pain when compared with no treatment at intermediate-term [RR 0.79 (95% confidence interval (CI) 0.59 to 1.06)] but not long-term follow-up [0.89 (95% CI, 0.65 to 1.21)]. There is low quality evidence (one trial, 102 participants) that a whiplash pamphlet on advice focusing on activation is less beneficial for pain reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short- or intermediate-term follow-up. Low to very low quality evidence (nine trials using diverse educational approaches) showed either no evidence of benefit or difference for varied outcomes. Advice focusing on pain & stress coping skills and workplace ergonomics: Very low quality evidence (three trials, 243 participants) favoured other treatment or showed no difference spanning numerous follow-up periods and disorder subtypes.  Low quality evidence (one trial, 192 participants) favoured specific exercise training for chronic neck pain at short-term follow-up.Self-care strategies: Very low quality evidence (one trial, 58 participants) indicated that self-care strategies did not relieve pain for acute to chronic neck pain at short-term follow-up.

AUTHORS' CONCLUSIONS

With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5

STUDY DESIGN

Expert debate and synthesis of research to inform future management approaches for acute whiplash disorders.

OBJECTIVE

To identify a research agenda toward improving outcomes for acute whiplash-injured individuals to lessen the incidence of transition to chronicity.

SUMMARY OF BACKGROUND DATA

International figures are concordant, estimating that 50% of individuals recover from pain and disability within 3 to 6 months of a whiplash injury. The remainder report continuing symptoms up to 1 to 2 years or longer postinjury. As no management approach to date has improved recovery rates, new clinical/research directions are required for early management of whiplash-injured patients.

METHODS

A group of multidisciplinary researchers critically debated evidence and current research concerning whiplash from biological, psychological, and social perspectives toward informing future research directions for management of acute whiplash.

RESULTS

It was recognized that effective treatments for acute whiplash are constrained by a limited understanding of causes of whiplash-associated disorders. Acute whiplash presentations are heterogeneous leading to the proposal that a research priority was development of a triage system based on modifiable prognostic indicators and clinical features to better inform individualized early management decisions. Other priorities identified included researching effective early pain management for individuals presenting with moderate to high levels of pain; development of best education/information for acute whiplash; testing the efficacy of stratified and individualized rehabilitation, researching modes of delivery considering psychosocial modulators of pain and disability; and the timing, nature, and mode of delivery of cognitive-behavioral therapies. Directions were highlighted for future biomechanical research into injury prevention.

CONCLUSION

The burden of whiplash injuries, the high rate of transition to chronicity, and evidence of limited effects of current management on transition rates demand new directions in evaluation and management. Several directions have been proposed for future research, which reflect the potential multifaceted dimensions of an acute whiplash disorder.

The role of educational and learning approaches in rehabilitation of whiplash-associated disorders in lessening the transition to chronicity

STUDY DESIGN

The study design was descriptive.

OBJECTIVE

The aim of this chapter was to illustrate and discuss educational and learning perspectives in the rehabilitation of patients with acute whiplash-associated disorders (WAD).

SUMMARY OF BACKGROUND DATA

WAD is a major problem for the individual and the society. Several treatment options have been studied without giving convincing results for lessening the transition to chronicity. Current management of acute WAD include among other things advice of exercise and educational activities.

METHODS

A literature search on the PubMed database was conducted with additional topic discussions with the research colleagues at a symposium. These resulted the present state-of-the-art review.

RESULTS

There are several possible cognitive factors and behavioral learning processes such as self-efficacy, fear of movement and (re)injury, and catastrophizing that are important to focus on in decreasing acute WAD to becoming a chronic condition. Learning based on behavioral medicine approach in physiotherapy framework has gained evidence in other musculoskeletal pain conditions.

CONCLUSION

Exercise, education, and learning with a behavioral medicine approach should be focused on in the future studies of acute WAD management.