The purpose of this study was to assess the effectiveness of a multimodal treatment program for patients with chronic symptoms after whiplash. 26 patients (13 male, 13 female) participated. All had experienced whiplash at least six months before the study and had experienced symptoms for an average of 20.8 months. All were partially or completely unable to work and had been absent from work for an average of 15.7 months.
A multidisciplinary team assessed all patients before treatment began. An orthopedic surgeon or neurologist conducted a full physical exam and assessed radiographs including extension-flexion films of the cervical spine. A physical therapist looked at cardiorespiratory fitness. Psychological assessment using MMPI-2 was done by a clinical psychologist. Neuropsychological screening was also done. An occupational therapist assessed the physical and mental demands of each patient's work. These assessments were used as baseline data to be compared with outcome data. Results of these assessments were shared with patients (and their partners) before the treatment program began.
Patients participated in a daily 4-week outpatient multimodal treatment aimed at restoring normal daily function. The patients were instructed to not use analgesics. It was explained that the purpose of the study was not to reduce pain, per se, but to increase regular functioning- including return to work. The program included physical training meant to end inappropriate pain behavior, restore muscle endurance and strength and to improve aerobic fitness. Group sessions were employed to discuss patient's deeply held beliefs on symptoms and disability.
Program outcome was measured using both self-report & objective criteria. Self-report measures included neck pain, headache, disability, fatigue, "vague" somatic symptoms, psychological distress, depression, and problems with concentration and memory. Objective measures looked at features of daily functioning such as return to work, drug usage, and medical consumption.
A six-month follow up assessment documented the program outcome. Statistically significant improvements on self-report measures were found. For somatic symptoms, 73% of patients fell within normal range. 96% rated within normal limits for psychological distress. 46% of patients were within normal health distribution for pain intensity (reportedly, nearly pain free). This improvement in pain levels occurred despite the fact that the treatment goal did not include pain reduction, and many of the activities required in the program could have increased pain. Follow up assessment of objective criteria showed a complete return to work for 65% of patients and at least partial return to work for 92% of patients. 81% of patients did not seek medical care during the follow up period. Only 58% of the patients reported no use of analgesics.
While improvement was noticeable in a segment of the test subjects, there were still a number of patients with pain symptoms. The authors address this issue:
"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 question is, why did some patients not improve?"
The authors suggest that patient beliefs are responsible for chronic whiplash symptoms, and they refer to the severely flawed Quebec Task Force and the Lithuanian studies as evidence that there are no physical reasons for chronic pain. The study completely ignores the vast body of literature on whiplash biomechanics that isolate the cervical facet joints as a cause of pain after whiplash injuries.
Vendrig A, van Akkerveeken P, McWhorter K. Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck. Spine 2000;25(2):238-244.
