Manual and Exercise Therapies in Whiplash-Associated Disorders

Manual and Exercise Therapies in Whiplash-Associated Disorders

Alice Kongsted


Manual therapy is hands-on techniques aimed at decreasing pain and restoring biomechanical function. The term includes joint manipulation, joint mobilization, and several soft tissue techniques such as massage, trigger point treatment, and stretching techniques. Different manual techniques are often combined in clinical practice. Exercise therapy can be defined as a series of specific movements conducted with the aim of training or developing the body [1]. Different types of exercise therapies aim at different effect mechanisms and include exercises aimed at decreasing pain, increasing muscle strength and endurance, increasing range of motion, normalizing muscle recruitment patterns, and exercises targeting impairments in balance and proprioception. In clinical practice, manual and exercise therapies are often combined and used alongside some level of patient information and advice.

Although there is a theoretical rationale for choosing the type of therapy based on physical impairments, it is only sparsely investigated whether treatment effects are actually mediated through altering the
impairments that the therapies are designed to address. There is evidence that impairments in muscle recruitment are improved by exercise therapies [2, 7, 8], but it is not clear whether clinical improvements can be attributed to change in biomechanical function. In low back pain, which to some extent resembles neck pain, most existing evidence does not support that observed effects of exercise therapies are mediated through improved muscular function [13, 17, 23]. Similarly, the effect mechanisms of manual therapies are largely unproven.


Treatment Goals and Rationale of Initial Care

Treatments provided in the acute phase after whiplash injuries should give direct symptom relief, but, even more importantly, prevent the development of a chronic pain condition. Mechanisms for the development of chronic whiplash-associated disorders (WAD) are not clear, and a specific diagnosis that could direct treatment choices can generally not be established. However, several factors have been identified that are associated with a poor prognosis after whiplash injuries, and it makes sense to address potentially modifiable prognostic factors in an attempt to prevent chronic WAD. Neck pain intensity and cervical range of motion, which are likely to be positively affected by manual therapy and exercises, are prognostic markers rather consistently found associated with an increased risk of long-lasting WAD [24]. Also, prognostic markers like recovery expectations, fear of movement, catastrophizing, and passive coping strategies may be indirectly affected.

In assessing any treatment effect, it needs to be recognized that single elements of a clinical consultation never work in isolation, and treatment effects result from specific effects of treatment techniques as well as from unspecific effects of the patient-clinician interaction. Clinicians offering manual treatment and exercise therapies often see a patient for a course of treatment, and will potentially affect patients’ expectations, beliefs, and fears considerably. This can either be through
a conscious attempt to do so or as an undeliberate result of patients’ interpretations of information and acts.

Observations of less favorable outcomes with more intense care raise the question of whether health care has iatrogenic effects in acute WAD [5]. It can be hypothesized that offering treatment in the acute phase after a whiplash injury may support an undesirable focus on symptoms or make patients think their acute symptoms are unexpected. On the other hand, it can be speculated that offering care that makes sense to patients will affect patients’ beliefs positively and that a course of treatment provides an option to deal with unsolved questions and worrying thoughts. It is unknown to what extent these mechanisms are in play and to what extent patients’ expectations and beliefs related to a whiplash injury are actually modifiable. Even with the same care offered, it is most likely that some patients get positive reassurance from the patient-clinician interaction, whereas negative beliefs are reinforced in others. Patients receiving more intensive care do on average have worse outcomes than those with fewer health care visits, but it is not clear whether this is caused by an iatrogenic effect of intensive care or whether the poor prognosis is a result of the factors that made patients seek more care.

Effects of Manual Treatment and Exercise Therapies as First-Line Care

There is no evidence that long-lasting WAD can be effectively prevented by any intervention offered soon after a whiplash injury. Still, the collective research effort does provide some guidance for acute whiplash care.

First of all, the recovery from an acute whiplash injury is not promoted by rest or immobilization. Previously, it was standard care in emergency units to provide patients with a soft neck collar to give pain relief and provide an opportunity for soft tissue sprains to heal. However, evidence consistently shows the absence of a positive effect of advocating rest as treatment in acute WAD. Any type of exercise therapy and also cervical mobilization is more beneficial [21, 22, 26, 27], and immobilization with a soft neck collar may even be harmful [26]. However, from one large trial it seems that prescribing a semirigid collar to severely affected patients apparently does not provide a worse
outcome than active strategies [12], and that use of a neck collar for a short period is not likely to be harmful when combined with adequate information. The lack of positive effects from immobilization may be because it actually does not stimulate tissue healing, or because of negative psychological effects, or a combination of the two. In parallel with results in WAD, the results of long-term immobilization as treatment for acute ankle sprains, which was previously standard care, also does appear unfavorable [11]. Like rest and immobilization, also passive physiotherapy modalities such as heat and electrotherapies have been proven ineffective in acute WAD [26].

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Apr 4, 2021 | Posted by in PAIN MEDICINE | Comments Off on Manual and Exercise Therapies in Whiplash-Associated Disorders
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