Article
Results of a Multimodal Treatment Program for Patients With Chronic Symptoms After a Whiplash Injury of the Neck
SPINE Volume 25, Number 2, pp 238–244
©2000, Lippincott Williams & Wilkins, Inc.
Abstract
Study Design
A descriptive case series pre- and posttreatment design, including a 6-month follow-up.
Objectives
The objective of this study was to document the improvements of patients with chronic symptoms after a “whiplash” injury of the neck, who attended a 4-week multimodal treatment program at the Rug AdviesCentra Nederland.
Summary of Background
Data
To the authors’ knowledge, no studies have been conducted on the effectiveness of multidisciplinary treatment of chronic symptoms after whiplash injury.
Methods
Twenty-six patients who experienced
Results
The patients’ symptoms improved significantly on nearly all
self-report measures. Their scores for objective outcome criteria reported
during the 6-month follow-up evaluation were: complete return to work (65%);
complete or partial return to work (92%); no use of analgesics in the past 6
months (58%); and no medical or paramedical treatments in the past 6 months
(81%).
Conclusion
These early results indicate that a multimodal treatment program has the potential to be an effective treatment for patients with chronic symptoms after a whiplash injury of the neck—a group of patients who have in the past been considered intractable or, at the very least, puzzling.
During rear-end auto collisions,
people are subjected to an extension–acceleration force, that often results in
the development of pain symptoms. The term “whiplash” refers to this mechanism.
After such an injury, people often report neck pain and numbness, dizziness,
and headaches. 1
Acute symptoms are attributed to lesions within the muscles and/or ligaments of
the neck (neck sprain), because evidence of skeletal or nervous system injuries
is absent in most patients. 33
However, evidence of structural damage beyond the average healing time is
seldom found among patients with whiplash, 5
even when sophisticated imaging techniques such as magnetic resonance imaging (
Clinical studies indicate that
between 14% and 42% of patients with whiplash injuries have chronic neck pain
and that approximately 10% of this group experience constant, severe pain. 6,8,11,19,22–24,26,37
Lower prevalences of chronic neck pain and headache among patients with
whiplash have also been found. For example, in
The costs in Western countries of chronic symptoms after whiplash injury in personal disability, work loss, and disability claims appear to be substantial and can even be termed epidemic. 5
Stovner 33 outlined that the concept of the “whiplash syndrome” will probably lead to a predominately trauma-oriented approach and may possibly divert the research from other, more productive approaches. One likely alternative is the behavioral approach, which has been shown to be quite successful in the treatment of chronic low back pain. Unfortunately, inappropriate pain behavior and distress have been poorly studied, although they may play a role in progression toward chronicity after a whiplash injury. For example, avoidance of normal neck movement may result in the so-called “disuse syndrome,”3 and, consequently, muscle atrophy. There is some evidence that decreased regional blood flow due to muscle atrophy is associated with neck pain. 18 Also, disturbed sleep patterns caused by distress and accompanied by hyperactivity of the trapezius muscle may lead to persisting pain and dizziness, while also reinforcing the distress. The ultimate consequence is a vicious circle, out of which the patient cannot escape.
Therefore, a multimodal treatment program may be the treatment of choice to manage the aforementioned processes and thus restore patients’ functioning and decrease the symptoms. However, the authors are aware of no empirical efforts in this area.
The purpose of the present study was to document the improvements of patients with chronic symptoms after a whiplash injury who attended a 4-week multimodal treatment program. The results at the end of the program and at 6-month follow-up are reported.
Methods
Study Design
The study was an uncontrolled pre- and post-treatment design, including a 6-month follow-up period. The outcome measures were assessed by independent observers who were not members of the treatment team.
Participants
The study took place at the (
The mean age of participants (13 men;
13 women) entering the program was 35.8 ± 8.7 years (mean ± SD). All patients
had symptoms, resulting from a whiplash injury that had occurred at least 6
months ago, with a mean duration of symptoms of 20.8 ± 10.2 months. All
patients had a
Procedure
Before participating in the treatment
program, all patients were evaluated by a multidisciplinary team. The
orthopedic surgeon or neurologist conducted a full physical examination and
assessed radiographs, including extension–flexion films of the cervical spine
and in a number of cases reviewed computed tomographic or
The results of the multidisciplinary
assessment were discussed with the patient and his or her partner during a
second visit. Patients who participated began the program within a average of 2
months after the assessment. At that time, all patients were required not to be
using analgesics. In some cases, the use of analgesics was reduced by using a
gradual, time-contingent protocol. It was explained that the intervention was
not directly intended to decrease pain but to increase normal daily activities,
the goal being a normal daily pattern of activities, including return to work.
“
The assessment data were used as pre-program (baseline) data. Program outcome was assessed at the last day of the program and at follow-up, approximately 6 months after the end of the program.
Program Overview
The program is a daily, 4-week, outpatient multimodal treatment program designed to restore a normal pattern of daily functioning, including complete return to work. Decreasing pain symptoms is not a direct goal of the program. The program is based on the principles of Fordyce 9 and Mayer and Gatchel. 21 The physical training according to operant learning principles (“graded activity”) is intended to abolish inappropriate pain behavior and to restore muscle strength and endurance as well as aerobic fitness. Pain behavior such as wearing a soft neck collar was also discussed by the treatment team and was reduced by the previously mentioned time-contingent protocol. Also, sport activities such as swimming and squash were part of the program. During the group sessions, patients’ deeply rooted beliefs regarding symptoms and disability were discussed. The occupational therapist assisted the patient in the process of returning to work.
Program Outcome
Measures
Outcome measures included both self-report measures and objective criteria. The self-report measures covered a wide range of symptoms often reported by patients with chronic symptoms after a whiplash injury. They included neck pain and headache, disability, fatigue and “vague” somatic symptoms, psychologic distress, depression, and difficulty with memory and concentration. Objective criteria focused on aspects of daily functioning, that have been described as relevant in chronic illness, such as actual return to work, medical consumption, and drug usage.
The MMPI-2 and the Quebec Back Pain Disability Scale (QBPDS; described later) were administered before entering the program, immediately after the program, and at 6-month follow-up. The visual analog scale (VAS) and pain drawing (described in the next section) were administered twice, before entering the program and at 6-month follow-up. These measures were not administered at program termination, because it would have been contradictory to the explanation to the patient that pain reduction was not the direct goal of the program.
Self-Report
Measures
Pain Intensity. The VAS assesses the intensity of the pain experienced by the patient on a 10-cm line. The VAS score can vary from 0 (no pain) to 100 (the worst pain ever experienced). The patient was asked to estimate the average amount of pain for the past week, including the current day.
Painful
Sites
The pain drawing 20 assesses pain distress and is scored according to the “pain sites” method described by Parker et al, 25 who found this method to be the method of choice for scoring pain behavior. The score for the pain drawing can vary from 0 to 45 assigned body parts.
Self-Reported
Disability
At the time of this study, there was no Dutch translation and reliable version of the Neck Disability Index 36 available. Besides this index, there are currently no other neck-specific disability inventories circulating. Therefore, it was decided to include the Dutch-translated and validated version 30 of the Quebec Back Pain Disability Scale (QBPDS), 17 although it was realized that this questionnaire is not tailored to neck disability. The items of the QBPDS do not refer to specific back-related questions, rather to common physical activities, and therefore the questions were suitable for the purpose of this study. The QBPDS was constructed using a conceptual approach to disability assessment and empirical methods of item development, analysis, and selection. Test–retest reliability of the Dutch version of the QBPDS is 0.90; Cronbach’s [alpha] is 0.95. 30
The Dutch translation 7 of the MMPI-2 4 was used for the assessment of the somatic symptoms, psychological distress, depression, fatigue symptoms, and memory and concentration problems. The first three clinical scales (the so-called “neurotic scales”) are generally elevated among people with chronic pain. These scales present a broad reflection of distress and contain more than 40 items indicating somatic symptoms. Although the complete MMPI-2 was administered, a selection of scales was made reflecting the disturbances prevalent in this population. It is important to note that the MMPI-2 scale names are used by convention and do not necessarily reflect the scale’s contents. The MMPI-2 scales assess the items specified between brackets. The selected scales were Hypochondriasis (Hs, 32 items: somatic complaints); Depression (D, 57 items: psychological distress, depression); Lassitude–Malaise (Hy3, 15 items: high loading on fatigue complaints); Mental Dullness (D4, 15 items: high loading on memory and concentration difficulties); and Lack of Ego Mastery, cognitive (Sc3, 10 items: high loading on memory and concentration difficulties). Scales D4 and Sc3 were selected because these scales load high on memory and concentration deficits as reported by patients with closed head injuries. 12 Test–retest reliability of the selected MMPI-2 scales ranges from 0.64 to 0.88 (M = 0.76). Internal consistency of the selected MMPI-2 scales ranges from 0.60 to 0.80 (M = 0.68). 7,13
Objective
Outcome Criteria
At the 6-month follow-up, it was documented whether the patient had achieved the goals of normal daily functioning: complete return to work, not even a single use of analgesics during the past 6 months to reduce the pain symptoms, and no medical or paramedical treatment for symptoms of whiplash-associated disorder. It may appear rather strict to regard the result a failure when, for example, a patient had taken a pain killer only once during the follow-up phase. However, this action was considered to be an indication of unchanged behavior. This means that the patient has not acquired new cognitions about his neck pain and performs activities still contingent on pain symptoms.
Statistical
Analysis
The statistical significance of changes on the metric measures between the program’s beginning and end and the beginning and follow-up was determined using paired t tests. However, a change in statistical terms does not necessarily indicate that this change is also clinically meaningful—that is, of clinical significance. A treatment that resulted in clinically significant improvement was characterized by notable improvement in a patient. Statistical significance, on the other hand, was defined as quantitative change in a group of patients. 32 Jacobson and Truax 15 developed a model to assess the clinical significance of individual improvement (the interested reader should refer to Jacobson and Truax 15 for the specific computational equations). Two questions are of interest according to this method: 1) Are the individual changes on the outcome measures due to the test–retest (un)reliability? This answers the question of whether the changes were reliable (RC). 2) Have the patients with a significant improvement “moved” from the dysfunctional (ill) population into the healthy population? Clinically significant change is defined as both end-state functioning within the healthy distribution (normal population) and reliable change. Reliable change is defined as 95% confidence in patient improvement, given the intrasubject variability and measurement error associated with the dependent measure. Reliable change indexes higher than 1.65 are regarded as reliable. 15
In this study, for each (metric) measure, the frequency of subjects was documented with RCs more than 1.65. A cutoff score of T = 65 (recommended by the MMPI-2 test publisher) was used to determine whether a patient’s end-state functioning on the MMPI-2 scales fell within the normal population. However, healthy normative data are not available for the QBPDS, VAS, and pain drawing, and end-state functioning on these measures therefore was defined as postprogram and follow-up scores that fell two standard deviations from the mean of the dysfunctional population in the direction of normal functioning, as recommended by Jacobson and Truax. 15
Results
Participants
Versus Non-Participants & Withdrawals
The sample of patients who participated in the program (n = 26) was compared with initially assessed patients who did not (n = 25). According to results of analysis of variance (ANOVA), no differences emerged between the participants and nonparticipants regarding age, duration of symptoms, and duration of work absenteeism due to symptoms. A multivariate analysis of variance (MANOVA) was performed to examine baseline differences (assessment data) regarding the clinical variables. On the multivariate test and the univariate tests, there were no group differences (P > 0.05) observed. Thus, the sample of patients in this study seems to be representative of the total population of patients with whiplash who used the services at one of the authors’ centers, at least in terms of the considered clinical variables, although it cannot be excluded that they are selective as a result of medicolegal status, funding, beliefs, and geographic location.
All patients who enrolled in the program, completed the program, and attended the follow-up sessions. Therefore, an analysis of withdrawals was not necessary.
Results
Before & After the Program and at Follow-Up
In Table 1, patients’ preprogram, immediately postprogram, and follow-up scores on the self-reported measures are presented. As outlined before, postprogram scores for VAS and pain drawing were not assessed for clinical reasons.
The preprogram data showed that this
sample of patients was very disturbed by pain, symptoms, and distress. The
relatively high scores on the MMPI-2 subscales D4 and Sc3 indicate that they
had problems with memory and concentration. Visual inspection of the mean
preprogram results compared with the mean postprogram and mean follow-up
results showed a dramatic decrease of disturbances before and after the
program, with a slight relapse after the program and at follow-up on some
measures. Paired t tests (preprogram score minus
follow-up score) with [alpha] set at 0.006 (0.05/8) for eight concurrent tests,
indicated significant changes on all measures.
Clinically
Significant Change
As indicated, the improvements during
the program on the self-report measures were statistically highly significant.
However, the question of whether these gains were clinically significant has
yet to be answered.
As can be seen in Table
2, postprogram and follow-up scores of most patients (<90%) on the
MMPI-2 scales fell within the healthy distribution. A slight relapse (from 92%
to 81%) emerged for Hy3 (fatigue symptoms), indicating that some patients had
more fatigue symptoms in the phase between program termination and follow-up.
After the program and at follow-up, approximately 50% of patients fell within
the healthy distribution regarding pain intensity and number of painful sites.
Thus, their level of pain was minimally different from the pain experienced by
healthy people. A further improvement regarding the decrease of disability
(QBPDS) emerged between the end of the program and follow-up: from 27% of
patients deemed “healthy” after the program to 38% deemed healthy at follow-up.
This difference is most likely because the patients were more active at home,
resulting in lower rates of self-reported disability. The overall clinically
significant change was between 30% and 50%. The relatively low clinically
significant change of QBPDS, in spite of its high accompanying RC, indicates
that many patients improved substantially regarding disability. However,
approximately 60% of them are still dysfunctional.
Objective
Outcome Criteria
Outcome in terms of “normal” functioning regarding work and health-care regulation is presented in Table 3. Considering the high levels of pain and distress before the program and the persistence of the symptoms since accident (M = 20.8 months), a complete return-to-work rate of 65% combined with partial return-to-work rate of 92% is very promising. During the follow-up phase, 81% of patients did not seek any medical care for symptom relief, such as conventional physical or chiropractic therapy. The lowest percentage of normal functioning was found in the area of analgesics usage; 42% of patients still used analgesics during the follow-up period.
Discussion
The results of this study indicate
that a multimodal treatment program has the potential to be an effective
treatment for patients with persisting symptoms after a whiplash injury of the
neck and therefore deserves further study in more powerful designs, such as a
randomized controlled design. This is also the first attempt to document the
outcome results of this treatment for patients with chronic symptoms after a
whiplash injury. Furthermore, multidisciplinary treatment programs have emerged
as more effective than unimodal treatments for patients with chronic pain, in
particular chronic low back pain and headache, 8
and the results of this study indicate that this may also be applicable for
patients with chronic symptoms after a whiplash injury.
Substantial improvements were
observed that were statistically and clinically significant regarding somatic
symptoms and psychological distress. At follow-up, 73% of patients fell within
normal limits regarding somatic symptoms, and 96% of patients regarding
psychologic distress. Moreover, although the goal of the program was not pain
relief and patients actually performed many activities as part of the program
that could have increased their pain, at follow-up, the pain intensity score
showed a reliable improvement of 54%, and even 46% of patients fell within the
healthy distribution (thus, they were nearly pain free) of this measure.
Although it could be inferred from these figures that still more than 50% of
patients with whiplash in this study did not improve substantially, it should
be realized that the operational approach of clinically significant change for
determining improvement is much stricter than a standard parametric test. In
one study, 32
clinically significant change was assessed in the behavioral treatment of
chronic low back pain, and the reported clinically significant changes varied
between 6% and 24%. In fact, a clinically significant change refers to normal
functioning after treatment and an improvement
that is of such considerable size that it must be attributed to the treatment.
The clinically significant and therefore meaningful changes shown in the
current study may therefore be attributed to the treatment interventions,
because such improvements would not be expected to occur spontaneously in
patients with such conditions, although some influence of a “regression to the
mean” may be present.
In line with the current view of outcome
assessment, objective criteria indicating daily functioning and activity
patterns were assessed. Considering that almost all patients had received a
wide range of unimodal treatments over a long period and had also long been
absent from work, the objectively assessed complete return to work of 65%, and
complete or partial return to work of 92% are promising.
Cognitive symptoms, in particular
symptoms related to memory and concentration, have a disabling effect on some
patients with persisting symptoms after a whiplash injury. The symptoms prevent
them in particularly from meeting the demands of their work. Although patients
often attribute these problems to a physical lesion as the direct consequence
of the accident, some prospective studies on this subject indicate that such
cognitive symptoms relate either to the trauma-induced symptoms, such as pain,
or to the psychological symptoms resulting from the reaction of the patient to
the symptoms. 28
In the program, no specific neuropsychological rehabilitation training was
offered. The observed decrease of reported cognitive symptoms, therefore,
offers indirect support for the theory of Radanov and Dvorak, 28
which views cognitive difficulties in the context of “chronic illness” and not
as an organic abnormality. Also Taylor et al 34
could not support the theory of neural degeneration in the cause of
whiplash-related cognitive symptoms, nor was the specificity of
neuropsychological tests in detecting subtle effects of brain trauma
demonstrated.
Two limitations of this study have to
be acknowledged. First, the design did not include a randomized control group,
the study design of choice. The use of a control group after the natural course
of illness or placebo use is, however, difficult to realize with cognitive
behavioral treatment programs. Only a few studies have been published using
waiting-list or placebo control groups. 35
The design used in this study may be considered valid because the patients
reported very long histories of pain and, therefore, it is not likely that the
short period of treatment (4 weeks) would be sufficient in the sense of the
natural history to account for the observed results. 10
To illustrate, epidemiologic studies demonstrate that those patients who still
have symptoms 3 to 6 months after the injury, in more than 80% of cases,
continue to experience symptoms after 2 years. 1,5
Therefore, if a waiting-list control group had been included, most likely no
major change of symptoms and daily functioning would have been observed within
the 4-week (treatment) or 6-month (follow-up) period. Again, the research
presented here can be thought of as repeated case studies, and it does not
provide the level of evidence to accept the applied treatment as a
scientifically proven and effective approach to patients with chronic whiplash.
To establish support in favor of the effectiveness of the cognitive behavioral
approach to chronic whiplash, a randomized clinical trial comparing this
approach with regular medical care (e.g.,
physical therapy) is needed. Such research would be of outstanding quality if
both statistical and clinical significance of treatments were assessed.
The second limitation of this study
concerns the multimodal treatment approach of the program. In fact, this issue
applies to multidisciplinary pain treatment programs in general. Because the
program consisted of a number of elements or cointerventions, it is difficult
to isolate the most powerful, or keystone, element responsible for the
improvements. For example, what would have been the outcome if the
psychological group sessions had been skipped, while the physical exercises was
retained? In one study, patients with neck pain without a past injury received
a graded-activity training program for the neck muscles. Results indicated
substantial pain relief, and 80% of patients returned to work within 8 weeks
after the program. 14
Again, such questions addressing the efficacy of treatment could only be
answered by a randomized clinical trial design.
As has been established for chronic
low back pain, cognitive behavioral treatment appears to be a promising
treatment for patients with chronic symptoms after a whiplash injury. However,
considering that more than 50% of patients did not show a clinically
significant change and 35% of patients did not achieve a complete return to
work, it is clear that there is still a great deal of work to be done. The
questions is, why did some patients not improve? Based upon the authors’
clinical experience and supported by clinical analyses of the failures of the
program, it appeared that the patients who achieved complete return to work can
be distinguished from those who did not. Those with failed treatment reported
high levels of pain at follow-up and showed a relapse of fatigue symptoms. It
is hard to draw firm conclusions at this point, because of the small number of
subjects as well as the design constraints and measures used. The authors
speculate that deep-rooted beliefs such as “first, I have to be painfree before
I can become active” may prevent the patient from escaping the vicious circle. Kellner
et al 16
showed that somatic attributions and fears are important predictors of the
persistent nature of somatic symptoms. And finally, considering that the
results in this group of patients reflect also the learning curve of the
treatment team, even better results may be expected in the future.
Conclusion
The results of this study indicate
that a cognitive behavioral approach has the potential to be an effective
treatment for patients with chronic symptoms after a whiplash injury of the
neck. Further research performed in randomized clinical trials is needed to
support and extend the findings. The improvements observed in this study may
provide indirect evidence that behavioral mechanisms contribute to the
maintenance of symptoms beyond healing time of whiplash injury.
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