FW: Whiplash - Spine. 2003;28(22):2491-2498

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Repeat of an old post.

s.fuchs dc

From: Sharron Fuchs

Sent: Tuesday, December 02, 2003

1:31 PM

To: 'Oregon DCs (E-mail)'

Subject: Whiplash - Spine.

2003;28(22):2491-2498

Active Intervention Best for Whiplash

News Author: Laurie Barclay, MD

CME Author: Vega, MD

Nov.

24, 2003 — Active intervention is more effective than standard care for

patients suffering from whiplash, according to the results of a three-year

follow-up of a randomized controlled trial published in the Nov. 15 issue of Spine.

" There

is no strong evidence for many treatments for whiplash-associated

disorders, " write Mark Rosenfeld, RPT, from the Sahlgrenska

Academy at Göteborg

University in Sweden, and

colleagues. " Some studies provide weak evidence supporting active

intervention. "

In

this prospective trial, 97 patients who sustained whiplash trauma in motor

vehicle accidents were randomized to an active intervention or to standard

care. Active intervention consisted of frequent active cervical rotation with

assessment and treatment according to McKenzie's principles; standard

intervention consisted of initial rest, soft collar, and gradual self-mobilization.

To

compare the effect of early vs. delayed initiation of active intervention,

treatment regimens were begun either within 96 hours or delayed 14 days from

the date of the motor vehicle accident. On average, the active intervention

required four treatment sessions.

Compared

with standard intervention, active intervention was associated with reduced

pain intensity and sick leave (P

< .05). Although delaying intervention by two weeks did not affect this

outcome, only patients receiving early active intervention had total cervical

range of motion at three years, which was similar to that of matched controls

who did not sustain whiplash.

" In

patients with whiplash-associated disorders, active intervention is more effective

in reducing pain intensity and sick leave, and in retaining/regaining total

range of motion than a standard intervention, " the authors write.

" Active intervention can be carried out as home exercises initiated and

supported by appropriately trained health professionals.... The emphasis should

be on frequently repeated cervical rotation. "

The

local research committee in southern Elfsborg

County, the Swedish

National Health Insurance, and the Vårdal Foundation supported this study.

Spine. 2003;28(22):2491-2498

Learning

Objectives

Upon completion of this activity, participants will be able

to:

Describe the symptoms and long-term prognosis of

whiplash-associated disorders.

Evaluate the efficacy of active vs. standard

intervention for whiplash injury.

Clinical

Context

Whiplash-associated

disorders can lead to both short- and long-term health problems. According to

the authors of the current study, short-term consequences of

whiplash-associated disorders may include neck pain, headache, shoulder pain, and

cognitive disturbances and other psychological symptoms. In a study of 108

patients analyzed 17 years after a motor vehicle accident, 55% reported

symptoms related to the accident, with neck pain and headache being the most

common complaints. The research by Bunketorp and colleagues, which was

published in the June 2002 issue of the European

Spine Journal, also demonstrated that one third of subjects with

residual symptoms claimed disability at work compared with 6% of subjects

without residual symptoms.

Standard

treatment for whiplash consists primarily of rest and a soft cervical collar

for comfort. A study by Rosenfeld and colleagues in the July 15, 2000, issue of

Spine challenged this treatment

regimen by comparing it with an active-treatment regimen consisting of early

and aggressive spine mobilization. At six months, subjects randomized to active

treatment reported less pain, especially when active treatment was initiated

within 96 hours of injury.

The

current study follows these same patients for up to three years to determine if

active treatment is superior in preventing long-term pain and disability. The

authors also compared cervical range of motion in patients with

whiplash-associated disorders to that of patients who had not suffered any

injury.

Study

Highlights

Subjects were selected from outpatient clinics

and emergency wards if they had history of exposure to whiplash trauma.

All patients underwent cervical radiography, and those with fractures, neurologic

deficits, or other complicated presentations were excluded.

Participants were randomized into 1 of 4

treatment groups: standard or active intervention initiated within 96

hours of injury, or standard or active intervention initiated after a

delay of 14 days.

Standard intervention consisted of advice on

suitable activities after injury and recommendations to rest the neck for

one week before beginning limited stretching several weeks after the

accident.

Active intervention incorporated treatment sessions

involving early cervical exercises that were to be repeated every waking

hour. If symptoms persisted beyond 20 days, subjects were reexamined with

a dynamic mechanical evaluation and given a personal rehabilitation

program.

Study outcomes included neck, head, and shoulder

pain at 6 months and 3 years after randomization. Subjects were also

evaluated for cervical range of motion between treatment groups at 6

months and against controls without a history of trauma at 3 years.

88 of 102 patients originally undergoing

randomization were available for analysis at 6 months, and the follow-up

rate at 3 years was 75%. Baseline characteristics between groups were

similar.

In the active-treatment group, the average

number of treatment sessions was 3.95. 63% of active-treatment subjects

had symptoms that extended beyond 20 weeks and received an individual

rehabilitation program.

Participants in both treatment groups

experienced reductions in pain at 6 months and 3 years compared with

baseline. However, compared with patients who received standard treatment,

the active-treatment patients experienced significantly reduced pain and

need for sick leave at both time points.

Active treatment was not statistically superior

to standard treatment in improving cervical range of motion, although

scores for range of motion at 3 years favored active treatment (P = .06 - .08). In addition, only the

active-intervention group that began treatment within 96 hours of injury

demonstrated cervical range of motion similar to that of uninjured control

patients at 3 years.

The delay in treatment from 96 hours to 14 days

did not singularly affect outcomes at 6 months or 3 years. However, a

2-way factorial design demonstrated that, in terms of improving pain

intensity and cervical flexion at 6 months, it was better to receive

active treatment early rather than late. Conversely, in the

standard-treatment group, it was better to receive treatment late.

Pearls

for Practice

Whiplash may produce multiple symptoms in the

acute phase that can become chronic medical problems.

Active treatment involving early mobilization

produces better outcomes than standard treatment for whiplash.