Grade II whiplash injuries to the neck: what is the benefit for patients treated by different physical therapy modalities?
From: Patient Saf Surg. 2009 Jan 16;3(1):2. [Epub ahead of print]
In a majority of cases, whiplash injuries are a domain of conservative therapy. Nevertheless it remains unclear whether physiotherapy is of medical or economic benefit in patients with whiplash injuries. The term “whiplash” in connection with motor vehicle collisions was first used by Gay and abbott in 1953 to describe the whip-like hyperextension with subsequent hyperflexion as a result of a rear-end collision. Meanwhile several studies
simulating whiplash, describe three reproducible phases of head-neck kinematics. In the first phase, the cervical spine shows a S-shaped curvature in which the more cranial motion segments undergo flexion, coupled with extension in the more caudal segments. It is supposed that injuries mainly located in the lower cervical spine are caused in this vulnerable phase. In the second phase, all segments of the cervical spine become extended, followed by a third phase in which the cervical spine passes once again through the initial position to finally reach maximum flexion.
Whiplash injuries represent one of the most common types of trauma in this age of increasing individual traffic mobility and their incidence continues to rise. After a complaint-free interval of a few hours to one day (five hours, on average), 47 – 88% of patients report pain in the neck. To describe the most determinant clinical symptoms, the Quebec Task Force (QTF) developed 1995 a classification system which allows a good assessment of the severity of the injury. In cases of QTF I° and II° whiplash injuries, the posttraumatic treatment is a domain of conservative therapy. Therapeutic measures have been exhaustively studied and compared. Physical therapy has been assessed predominantly with respect to its effects on pain intensity and improving patients’ range of motion. It seems that its efficacy is limited to a certain degree of improvement of these parameters in the acute stage of convalescence.
The quality of past studies, however, has been criticized and the therapeutic recommendation to “act as usual” has been considered adequate for comparable therapeutic success. There is, therefore, the overall impression that, compared with a spontaneous clinic course, physical therapy results in no statistically measurable advantage and the costs associated with physical therapy are not justified. It is important to note, however, that the effect of physical therapy in whiplash associated disorders has only been investigated in mixed QTF I and II populations. Considering the better prognosis of QTF I compared to QTF II injuries, it is probable that the therapeutic outcome of previously conducted therapy studies constitute a false-positive evaluation of the QTF II sub-populations.
Because 84.5% of the costs due to whiplash injuries are caused by the 38.5% of patients whose absence from work lasted more than two months, the aim of acute therapy in view of cost saving must be to achieve the maximum reduction in healing time and thus reduce the period of disability. To date, only three therapy studies have addressed the “period of disability” as an outcome parameter. The results of these studies, however, are contradictory and it is unsolved to what extent therapeutic measures may reduce the period of disability and contributes to cost savings.
It remains unclear whether physical therapy is of medical or economic benefit in patients with whiplash injuries. The present study is, to our knowledge, the first to simultaneously compare the efficacy of two physical therapy regimens and the recommendation to “act as usual” on the basis of clinical (pain intensity, range of motion) and economic (period of disability, sickness costs) outcome parameters in patients suffering acute whiplash injury.
Seventy patients with acute Quebec Task Force (QTF) grade II whiplash injuries were randomized to two therapy groups and received either active (APT) or passive (PPT) physiotherapy. Patients were compared with regard to pain and range of motion with data obtained in an earlier study from a group with grade II whiplash injuries in which the therapy recommendation had been “act as usual” (AAU; n = 20). The above-mentioned parameters were assessed at 24 hours and two months after the injury. Furthermore patients’ period of disability was documented after two months. RESULTS: After two months, patients in both the APT and PPT groups showed significant improvement in the median period of disability (active: 14 days; passive: 14 days) compared to the AAU group (49 days). No group difference was observed with regard to median improvement in range of motion (active: 120degrees; passive: 108degrees; activity as usual: 70degrees). The median pain reduction was significantly greater in the APT group (50.5) than in the PPT (39.2) or AAU group (28.8).
This study shows that the effectiveness of physical therapy and the recommendation to “act as usual” varies strongly in dependence of the outcome parameter we look at. There was no statistically significant difference in the improvement of range of motion deficit of the cervical spine observed in the groups receiving active or passive physical therapy and the group receiving the recommendation to “act as usual”. The effects of physical therapy on range of motion are discussed controversial in the literature. While a few studies (observation periods of 4-12 weeks) reported a significant improvement in range of motion in patients receiving physical therapy compared to a spontaneous clinical course, this was not confirmed by other studies (observation periods of 6-26 weeks). Because physical therapy appears to have only a limited effect in comparison with the spontaneous clinical course and limitations in range of motion resolve without treatment in many patients within eight weeks of the injury, it is understandable that differences between the various therapeutic options are difficult to
demonstrate.
With respect to pain intensity, previous studies have shown that activity and physical therapy result in enhanced pain reduction compared with inactivity. Analogous to our results, Mealy et al. showed that “active” physical therapy resulted in superior reduction in pain intensity than did “passive” physical therapy. Furthermore, our results confirm the findings of two other studies that found a significantly better reduction in pain as a result of active physical therapy compared to the recommendation to “act as usual”. Only Borchgrevink et al. consider the recommendation to “act as usual” to be sufficient. In our study, the initial pain intensity of the AAU group was very low compared with the other groups. The subgroup analysis of the AAU group in our study suggests that patients with initially low pain intensity are willing to accept the recommendation “act as usual”. Seen from this perspective, the data of the Borchgrevink study and those of the present study could be interpreted to mean that “act as usual” may be an adequate approach for QTF grade II populations with initially low pain intensity. On the other hand, whiplash patients with high pain intensity are not satisfied with the recommendation to “act as usual” and in many cases seek an alternate therapy prescribed by another physician or other healthcare provider. In the end, the patient acts on his own to “correct” the prescribed therapy but at the same time incurs additional healthcare costs.
Most of the financial cost of whiplash injuries relates to the resulting inability to work. Few studies, however, have addressed whiplash patients’ period of disability. In one study, Pennie et al. found no difference in the length of the period of disability between patients undergoing “active” physical therapy and those treated with simple immobilization of the cervical spine. In agreement with the findings of the present investigation, however, two studies found that physical therapy significantly reduced the period of disability. Since the two physical therapy programs in our study did not differ significantly in terms of their effect on the period of disability, it would appear that which type of physical therapy a patient receives is less important than the fact that some form of physical therapy is offered.
The findings of the present study show that the importance of physical therapy in patients with whiplash injuries varies significantly in relation to outcome parameter. Thus, a referral for physical therapy may not be considered medically necessary for restoring range of motion, yet it would appear to be extremely important from an economic standpoint in reducing patients’ period of disability. From the patients’ point of view, however, reduction in pain intensity is the most important goal. Here, prescription of “active” physical therapy should be preferred. Considering all these factors, active physical therapy is recommended for patients with QTF grade II whiplash injuries as the best option for achieving both therapeutic and economic objectives.
