Exercise for chronic whiplash – the road to Nullville.

It seems like only yesterday I was blogging about an important trial of targeted care for acute whiplash, which like other such trials returned a convincingly negative result. It seems that our best efforts at improving outcomes in the early stages after whiplash injury do not achieve their goals. But what about when we intervene with a group of patients who are already suffering from persistent symptoms? We may not be great shakes at preventing chronicity but are we any good at treating people who have established chronic whiplash associated pain?

A new trial, published in the Lancet, from a team of big hitters asked that question. While the existing evidence suggested that physiotherapy exercise programmes may not be very effective, it was hypothesized that a “comprehensive” exercise programme might do better. So 172 chronic whiplash patients were randomised to either a single 30 minute session of advice based around a self-help booklet and some generic and basic exercises or a course of 20 individually tailored and supervised exercise sessions with physiotherapists, comprising muscle balance/ postural training, sensorimotor exercises, integration of these motor control exercises to more functional movements, and a graded activity programme oriented to patients own functional goals. Pretty comprehensive stuff. No one-size-fits all concerns to worry about. A little manual therapy was allowed in the early stages and aerobic exercise was also incorporated.  Now I would predict at least a small non-specific effect just as a result of all that extra attention, but how much difference did it really make?

None, really. Across a range of outcomes there was no difference, and no hint of a trend towards a difference on pain, disability, quality of life or range of motion. In fact the only statistically significant, though clinically unimportant, differences between the groups were in self-rated recovery and functional ability, and that was short lived for functional ability. The authors also looked to see whether signs of CNS hyperexcitability, post-traumatic stress or duration of treatment affected the outcome. They didn’t.

So here we have a tight, well conducted trial of good size. It navigates the issues of treatment fidelity by delivering what only a real curmudgeon would deny is a comprehensive and well-designed exercise intervention. Yet even with the leg-up offered by a minimal care comparison the intervention achieved nothing of note.

This is an important trial. Conceived by leading thinkers in whiplash treatment and designed and conducted well, it is about as conclusively null as it could be. It sits within a growing body of evidence that indicates that whether acute or chronic, more comprehensive rehabilitation and treatment for whiplash does not enhance clinical outcomes. This includes some population based studies which suggest that more treatment may actually worsen the outcome (see here, here, here  and here).

It is an integral part of the culture of physical therapies to struggle with the idea that we should treat less. But while they might seem disappointing these findings have  potential benefits both for efficiency and for avoiding exposing patients to unnecessary treatment. Not the outcome we may have wanted, but certainly an outcome that can inform practice.

Neil O’Connell

Neil O'Connell 2As well as writing for Body in Mind, Dr Neil O’Connell, (PhD, not MD) is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist.
He also tweets! @NeilOConnell
Neil’s main research interests are chronic low back pain and chronic pain more broadly with a focus on evidence based practice. He has conducted numerous systematic reviews including some for the Cochrane Collaboration. He also makes a mean Yorkshire pudding despite being a child of Essex.
Link to Neil’s published research here. Downloadable PDFs here.

References

Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, Connelly L, & Sterling M (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet PMID: 24703832

Cassidy JD, Carroll LJ, Côté P, & Frank J (2007). Does multidisciplinary rehabilitation benefit whiplash recovery?: results of a population-based incidence cohort study. Spine, 32 (1), 126-31 PMID: 17202903

Côté P, Hogg-Johnson S, Cassidy JD, Carroll L, Frank JW, & Bombardier C (2005). Initial patterns of clinical care and recovery from whiplash injuries: a population-based cohort study. Archives of internal medicine, 165 (19), 2257-63 PMID: 16246992

Côté P, Hogg-Johnson S, Cassidy JD, Carroll L, Frank JW, & Bombardier C (2007). Early aggressive care and delayed recovery from whiplash: isolated finding or reproducible result? Arthritis and rheumatism, 57 (5), 861-8 PMID: 17530688