Whiplash and Early Intervention: Active Mobilization vs. Standard Treatment
Although little exists in the literature to recommend it, the standard treatment (rest, the use of a soft cervical collar, and gradual self-mobilization) is still commonly prescribed in cases of acute whiplash. A new Swedish study1 was done to compare the efficacy of an active treatment protocol, as outlined by McKenzie2, and standard treatment. The study also compared the effectiveness of early treatment to delayed treatment.
Eighty—eight (88) patients with whiplash caused by a motor vehicle accident (MVA) completed the study. They were randomized into four groups: patients were assigned to active treatment, standard treatment, early treatment, or delayed treatment group. Range of motion and pain were measured at initial study registration, and again at six months.
At the six-month follow up results showed that active treatment was more effective than standard treatment in reduction of pain. The two treatment methods achieved the same results for cervical range of motion. Further analysis of treatment onset and type demonstrated a combined effect. The active treatment protocol was more effective when initiated early. When treatment was delayed, standard treatment was more effective for both pain reduction and increased cervical flexion than it was when standard treatment was initiated early.
Patients in the active treatment group were assigned a posture and active exercise program consistent with McKenzie's principles. They were instructed to do active, gentle, small amplitude and range rotational neck movements, in one direction and then the other. Every waking hour, the movements were done ten times in each direction. The study participants were directed to do the exercises in the sitting position—if symptoms were not too intense—up to a maximum comfortable range. If the sitting position proved too painful, patients were instructed to use the unloaded supine position. Before the program of at home exercises began, guidelines were given to teach the patients to recognize warning signs that might indicate possible symptom recurrence or exacerbation. If symptoms did increase, treatment was altered to reduce the number or amplitude of movements, or both. If symptoms were still present twenty days after the MVA, a dynamic mechanical evaluation (consistent with the McKenzie protocol) was administered. After evaluation, additional movements (cervical retraction, flexion, extension, rotation, lateral flexion, or a combination depending on the patient's needs) were added to the original regimen of rotational neck movement.
Patients assigned to the standard treatment protocol group were given a leaflet of information on injury mechanisms, advice on suitable activities, and postural correction instructions. The leaflet advised patients to rest the neck during the first weeks after injury; it also informed patients that a soft collar could prevent excessive neck movement and provide comfort. The leaflet instructed patients to begin a program of movements to be done two to three times daily a few weeks after injury. The movements recommended in the leaflet were: elevation of the shoulders, retraction of the shoulder blades, torso rotation, lateral flexion of the head, rotation of the head and combined flexion-rotation of the head.
The results of this study confirm that frequent active mobilization exercises decrease symptoms more than a gradual mobilization treatment program. The question of whether or not a standard treatment program is detrimental cannot be answered by this study. Those patients that received standard treatment instructions did improve slightly, but the authors ponder, "...perhaps improvement would have been better without those instructions."
Improvement in range of motion after 6 months was the same for patients in both treatment groups. It is possible that the active treatment group could have shown a greater improvement in the first months as seen in other research. But, it seems that in time, regardless of treatment, most patients will regain range of motion.
This study concludes that early treatment with frequently repeated active movement, along with mechanical diagnosis and therapy is more effective for reducing pain in whiplash patients than standard treatment. It seems that an active treatment protocol may be beneficial not only to the patient, but also to the healthcare system in general. The authors theorize:
"If this therapy is performed as home exercises, initiated and supported by a physiotherapist, it could demand relatively small resources. Although no cost analysis was made in this study, it is reasonable to assume that patients with less pain use fewer resources in the healthcare system."
- Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders a comparison of two treatment protocols. Spine 2000; 14(25): 1782-1787.
- McKenzie R. The cervical and thoracic spine, mechanical diagnosis and therapy. Waikane: Spinal Publications, 1990:200-3.
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