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

Comments

  1. erratum: “nihil nocere” is the correct term

  2. Thank you for your enlightening comments. I stick by John Quintner’s position, regarding those effects primarly as kind of placebo reactions; enhanced by the doctor’s charisma and convictions.
    I have seen patients developping chronic pain while receiving correct treatment and I stick to the theory of chronic stress, disturbed hypothalamus-pituitary-adrenal-axis after severe adverse experiences (in early childhood). On base of chronic stress stems the inability or reduced ability to respond to ordinary treatment – just in a bodily way.
    This is not specific to chronic pain after wiplash injury but does not exclude it either. If you search in literature you will find enough hints and papers backing up this theory. If you follow this theory it is obvious that these patients cannot be helped in simple way – if they could be helped at all. Or we have to withdraw to “nihil nisi nocere” = not to harm (further).
    (Please be lenient with my English as it is not my mother tongue and thank you for the oppertunity to take part in this discussion.)

  3. John Quintner says:

    Georgie, all I can add is that placebo moves in a mysterious way its wonders to perform. [with apologies to William Cowper]

  4. John, although the therapeutic alliance is very important, this doesn’t explain why people recover when they read my book and follow the advice, or any other book on the subject, without even seeing a practitioner. Others might come to me but be struggling to accept the concept initially, but once they really begin to follow the advice, see the links etc, then they begin to progress – this again isn’t related to how often they see me or how well they know me.

    Got to go as I am presenting at the London Back Pain Show this week, but have a great day/night. 🙂

  5. John Quintner says:

    Georgie, might I suggest that your positive outcomes have more to do with you as a person and the way you approach a person in pain than with the theory or theories that you espouse? More strength to you!

  6. All I can say John is that I find it very sad to read comments like yours. In the 7 years of changing my whole approach from using physical approaches to what I then believed to be completely physical conditions (and getting increasingly frustrated with only being able to ‘manage’ patients’ chronic whiplash/pain), I now help people fully recover and usually after they have been to see numerous specialists and therapists who were unable to recognise that their mind had anything more to do with their pain than ‘affect’ it.

    As has already been mentioned, patients, just like so many Practitioners, might never open up to the concept of psychophysiological disorders, (i.e. TMS/MBS) in which case any treatment that can help, so why ‘down tools’ if you are at least helping them? Luckily many do, sometimes years after first hearing about this concept and approach, then begin to accept it and therefore take action and begin to recover.

    Thankfully as far as I am concerned, many Doctors and physical/mental health therapists are beginning to really take this on board and seeing just how effective the approach is through practice-based evidence, while the RCT’s and other evidence base grows. I am well aware though that you cannot ‘convince’ people of anything, least of all this and it is all part of evolving personally and professionally in your own way and this depends on your own experiences.

  7. John Quintner says:

    Irene, I agree that it might be a nice story but I cannot get past the nonsense of Tension Myositis Syndrome (TMS) /Mind Body Syndrome (MBS). May others have better luck than me!

  8. thanks for the link. Dr Schubiner’s approach sounds reasonable and I like his descriptive examples. Nethertheless and unfortunately my experience is that life is not that simple. It does not work like this and patients are often very, very reluctant to accept any pain theory that does not rely on tissues; from very the beginning of their suffering. They make me feel helpless though I – as a physiatrist – keep discussing tricky cases with my husband who is an experienced psychotherapist.

  9. No one knows. Down tools, John – that fits well into ‘First – Do no harm.’

    I have some patients who take their medically unexplained pain that they can accept as an output of a nervous system that exists in the absence of damage (this having been ‘confirmed’ on MRI to their satisfaction) and go running. From home bound and disabled by pain experiences to work and cardio-vascular exercise. They have pain when they set out, they have pain during the run and they have pain afterwards – at least they have lived to their value of contributing towards their well-being by running. Same for work or whatever their values are.
    I have others who cannot believe in medically unexplained symptoms – those for whom the metaphors do not stick, for whom the stories do not fall on fertile ground. Those are trickier – David Butler helpfully identified the people who you cannot reach as ‘sandstone’.
    A lot of those ‘sandstone’ people I see are those who have been so damaged by the processes of the medical model, its failure and its failure to tidy up after itself when it fails. Like cultists who cannot be deprogrammed. They just want to join in again for another round of assessment and further diagnostic dissonance. And its on a massive scale. A third of primary care consultations are for medically unexplained symptoms causing distress. Whiplash is a tip of a big ‘berg.
    So Quo Vadis? I don’t know – I am looking for signs to follow at least and questioning the directions that I have been given.

  10. John Quintner says:

    @ Michael. In the context of this discussion, the only honest answer for physical therapists is to “down tools”. We do know that the the evidence base for the available medications is disappointing, and that invasive procedures (including “dry” and “wet” needling) performed by interventional enthusiasts are controversial, although it does depend upon who you ask to provide the evidence. Monetary reward also needs to be factored into the equation. Quo vadis?

  11. Michael Ward says:

    Neil, thanks for commentary, also to all the other contributors for their perspectives. I agree that it does inform our practice and we should not waste time on courses of treatment that dont show benefit. If we were to exclude the pathological states as per John Q, How would you intervene in the patients described in the study?

  12. Hi John. That’s fine. I kept thinking I wouldn’t add anything further because I realised it wasn’t sticking to the topic of whiplash, but then someone would ask me a question. 😉

    I will therefore opt out now, but my email is georgie@sirpauk.com if you do want to get in touch.

    Best wishes, Georgie

  13. John Quintner says:

    Georgie, may I extend my offer to you? I don’t think we can progress this discussion much further and we are way off topic!

  14. First, I personally believe this is more than we can, and maybe ever will, be able to explain neurophysiologically, and secondly as we are potentially changing mindsets/beliefs about the cause of chronic pain, I recognized very early on that we can’t *convince* anyone that ‘this is right’, so to speak.

    John I like your explanation and yes my findings are that frequently the ‘priming’ experiences were in place well before any pain. Personality traits and beliefs are also very much part of this, hence why childhood experiences play such a part. e.g. Expectations that doing something, like picking up something heavy for example, could cause you ‘damage’, could well cause pain (or a perceived’ injury’) while stressed. Growing up with a parent who has chronic or recurring pain can result in pain in later life for a child due to the belief that it ‘runs in the family’. One study undertaken in Germany after the Berlin wall came down showed the increase in LBP over 10 years in East Germany (to the level in West Germany) and suggested (tongue on cheek) that maybe it spreads like a virus because they couldn’t explain it.

    My understanding is that chronic pain becomes learned and central sensitization plays a part here. However, can we say that sudden onset/acute pain is ‘learned’, apart from as John says, due to learned experiences? Or is something else going on?

    I am primarily a clinician and regularly see people who have developed pain (which often becomes chronic) doing something completely innocuous, something they regularly do or in fact, nothing. I also sometimes see people whose chronic, severe pain just resolves in days, or even in minutes, as they begin to accept on a deep level the truth of their pain experience. Can we really explain this completely on a physical basis?

    I consider it to be a maladapted stress response, with the symptoms ‘protecting’ the individual from a perceived threat. The threat is often that of showing our vulnerability, such as a surfacing emotion that might threaten our self-image. Or even for one GP patient I treated, his inability to write after his brain made the connection between nearly dying when he collapsed at his desk (while writing) with life-threatening heart problems. Much to his amazement he recovered by allowing himself to acknowledge how he had really felt when he thought he was going to die, then using visualisation and positive self-talk before and then after a few days he began writing (a nursery rhyme initially!) without any further problems.

    Maybe not in-depth scientific explanation, but for me this answered all the anomalies I had been noticing for years between the pain my patients presented with and the physical explanation for it.

  15. John Quintner says:

    Stuart, if you provide me with your email address, I will forward to you a recently published book chapter authored by Pamela Lyon. I believe she has provided us with a scaffold upon which we should be able to assemble a cogent scientific hypothesis that is somewhat along the lines you suggest. But I could be wrong!

    My email address is: jqu33431@bigpond.net.au

  16. stuart miller says:

    John, would you agree that the preparatory state of the person for responding to threatening input is established via learned experiences ? The person, if stressed, (with lack of info, uncertainty and loss of control as well as without emotionally supportive relationships) is ‘wired for sound’. To switch out of this heightened preparatory framework/state would require a different model for understanding of what is happening to them. I really like the conversation you mentioned explaining central sensitization which starts with the damaged cell and works out to the surrounding milieu including afferent nerve fibres and out from there.
    It would likely have to be reflected on to become personal possibly to stick. I really appreciated the insight of Andrew Koob’s The Root of Thought – after reviewing Dr. Howard Schubiner’s recent article, neural pathways may not be all that important to address. Please provide insight. Thanks.

  17. John Quintner says:

    Georgie, Dr Howard Schubiner has fallen into the trap of attempting to reify the lived experience of pain. I submit for your consideration that “pain” is not a learned experience (or skill). Can you convince me otherwise?

    However, I agree that from what we have learned about the property of neuroplasticity, all of our experiences are dynamic and modifiable, and are to some extent dependent upon context.

  18. Yes John, shell shock/PTSD fit the same concept. You might be interested in this recent article in Psychology Today by Howard Schubiner MD who explains how pain is learned. http://m.psychologytoday.com/blog/unlearn-your-pain/201404/the-role-neuroplasticity-in-pain-better-or-worse/

    Not specific to whiplash, but any chronic pain.

  19. John Quintner says:

    Georgie, the study you refer to is fascinating. When I researched the phenomenon known as “shell shock” that was not uncommon during WWI, I was struck by the fact that pain was NOT reported as a symptom. The various neurological syndromes that comprised “shell shock” indicated that certain cortical functions were being inhibited through primitive psychologically-induced mechanisms. Pierre Janet, who coined the term psychasthenia, provided possible explanations that were quite sophisticated.

    Would you care to comment?

  20. Hi Guys, I would like to comment on two particular points made in this interesting thread. I would suggest that the ‘Explain Pain’ work provides great grounding on what is potentially happening neuro-physiologically, but even with this work the understanding is that emotions/stress affect pain, but don’t cause it, therefore the emphasis is still on ‘management’, rather than recovery. Interestingly I attended a course by Lorimer Moseley just before I came across Dr Sarno’s work and it helped me when I began to discuss the neuro-physiology behind stress-induced symptoms with the other Specialists in the US.

    I am a Physio and I have now been working non-hands on for 7 years and yet observing better results than I have ever seen before with people who have been suffering from chronic, and often debilitating, pain for years. BUT – I am not and don’t want to be a Psychotherapist, although I have been on a couple of short counseling and coaching courses. Yes we do need to hone our communication skills when working in this field, but I would suggest what I do is more coaching.

    It is more about education and helping patient identify the links and triggers of their pain (current and past stress/trauma, personality traits etc) and then provide advice and self-empowering strategies to help them on their journey to recovery. Some of the strategies most often used are therapeutic journaling, mindfulness and CBT tools. Not that different from what is currently on offer in the NHS Pain Management Programmes, but the emphasis is that they are actually fit and well and that it is just learned nerve pathways causing the pain, which can be changed. Being able to overcome their old beliefs and the fears based on how people explain their pain to them is crucial to whether they recover or not.

    Yes I do refer on to Psychotherapists, as Dr Sarno did, but this is a small minority because my findings are that by providing plenty of self-empowering strategies and advice, plus ongoing support where necessary, is often all that is required.

    Out of interest, this study was published recently, which is the first to demonstrate that repressed emotions could well cause physical symptoms. http://www.bloomberg.com/news/2014-02-17/freud-s-hysteria-theory-backed-by-patients-brain-scans.html

  21. John Quintner says:

    @ Andrew. It is with some trepidation that I respond to your post!

    According to the latest reviews in a supplement to the journal Pain Medicine, the current evidence base for the application of so-called mind/body therapies to people experiencing chronic pain does seem to be rather weak.

    Are you suggesting that manual therapists be retrained as (or evolve into) psychotherapists? If so, they may quickly discover that they are not alone in their relative therapeutic impotence.

    However, if it is any consolation, in my opinion the specialty of Pain Medicine is facing similar problems. In the USA, its armamentarium of drugs and invasive procedures has come under attack from a number of different directions.

  22. Hi Neil, As with the manual therapy study this is proving the limitation to the current physiotherapy approach to chronic spinal problems . Rather than assume the attitude of advising us to “do less” I hope it spurs us on to look for what does work ( somewhere anywhere! ) and evolve as a profession.
    I am with Georgie on this in that I believe In the mind body connection and changing patients perceptions/beliefs of their pain and in managing their stress response to perceived threats.

  23. John Quintner says:

    David, as you would well know, third party insurers are likely to seize on these published and credible findings and accordingly limit their liability to pay for physical treatment. Why would they continue to fund a treatment modality that has not been shown to produce better outcomes than simply giving patients a bit of advice and a fairly bland booklet?

  24. Hi John, I can see why people often don’t go along with Dr Sarno’s theories because there was no real evidence base. That is why at the first conference in 2009 it was agreed it was important to develop this and more clearly explore what is happening neuro-physiologically, as well as demonstrate the results that so many of us are seeing with our chronic pain patients.

    Howard Schubiner MD is the main researcher in this field and in the UK we are also now developing some smaller studies and building an evidence base. It might take time, but in the meantime because of the often life-changing results so many of our patients have, which are maintained, I am passionate about continuing to build on my own work in this field.

  25. Thanks Heidi. For some reason the comments just looked like they hadn’t been sent at all.

  26. John Quintner says:

    @ St5e. I am talking about rigorously following the well-trodden path of the scientific method. If we are unable to make an accurate diagnosis, let us be completely honest with ourselves and with our patients. By all means attempt to relieve distress but let us not pretend that we know for sure that the pain of a particular patient is perpetuated by psychosocial factors. By the way, there is no such thing as a biopsychosocial “model”. Rather it is a framework or aide memoire to help clinicians better engage with their patients.

  27. Hi John,
    If we were to assume that these patients have dorsal root ganglion injuries. That these injuries have these effects that we see clinically as chronic pain. How else would we treat them? Assess, re-assure, normalise and return to function. A life well lived with pain – better than the alternative whcih I often see of a life disabled and blighted by pain. Whatever the root. The ends of the BPS approach ‘living with pain’ work for whatever medically unexplained symptoms we are presented with in clinic – as long as we get engagement in the model. The only thing that will reliably block engagement is the lure dangled by the culturally dominant medical model that if we can diagnose it we can fix it. Just let me refer you on to the next specialist. And the next and the next. All the while life on hold, waiting waiting for the fix that never comes. Because if the fix where to come as implied, promised hoped for then all the suffering to live well in the present would be made nothing. The medical model stuffs us John.
    Would saying to my next WAD patient – you have a cervical dorsal root ganglia injury help them – are we going to be putting dorsal root ganglia stimulators in these folk? I doubt that. But whatever they rock up with that is a distressing experience of pain we can help with that. As long as the lure and bear trap of the medical model keeps off their path.
    Kind thoughts,
    Steve

  28. John Quintner says:

    @ Neil. I have long been concerned that unrecognized injuries to cervical dorsal root ganglia may explain some of the poorly understood clinical phenomena reported in patients presenting with whiplash-associated disorders. I accept that testing this hypothesis has not been possible to date but the post-mortem studies originally reported by Perth anatomist Professor Jim Taylor certainly pointed in this direction. If this is the case, I cannot see that there is a place for exercises, neuroscience education or other psychological approaches.

  29. Neil O'Connell says:

    Hi Steve,

    Good question – not aware of any trials but I may have missed them.

  30. i would have thought that if anything the Hawthore effect would have been demonstrated in the group that had 20 sessions of individually tailored exercise with a little bit of manual therapy thrown in for good measure? I admit that I am suprised that this group showed no improvement.

    There is a cultural expectation that for whiplash (amongst other things), that some sort of manual therapy is necessary. If this expectation isn’t met then you will get a disgruntled patient who, begrudgingly will seek out private providers who will meet their needs.

    Unless large numbers of care providers use the information from studies such as this to scale back their interventions to a sound assessment and advice then this expectation will continue.

    David

  31. Hi Neil,
    How does the ‘Explain Pain’ neurophysiological pain education approach to normalise and re-assure the chronic neck pain patient compare.
    In contrast to the ‘my ongoing pain represents ongoing damage’ self-sustaining belief set the ‘my ongoing pain represents adaptations within my nervous system and so now in this part of my body I will experience pain sensations in response to the normal function of healthy tissues’? And then graded exposure to defuse from those painful sensations and the thoughts and behaviours that arise from them – not to make tissues stronger or longer – because the tissues aren’t the issue.
    The barking dog bothers me less now I know its not in distress.
    Kind thoughts,
    Steve

  32. John Quintner says:

    Sarah, are you describing what is known as the Hawthorne effect?

  33. Neil O'Connell says:

    Thanks for your comment Sarah. Interesting idea. There are some data that suggest otherwise – like this that we blogged on a few months ago: http://www.bodyinmind.org/targeted-therapy-for-acute-whiplash/

  34. I would not dispute the findings in this study (and others of it’s kind). What I do find strange however working in a chronic pain setting is how the expectations of patients with whiplash is that they should have received manual therapy treatment in their acute phase and are often critical of NHS treatment, their anger and resentment often seems to be a barrier further down the line in them engaging in therapeutic activities with any real commitment. They will often report that their only relief has come about when they have paid private practitioners and been given actual hands on treatment – why is this I wonder? One would almost imagine that giving a patient what they believe they need in the acute phase would be more successful if for no other reason than as a placebo. Quite possibly all our hands on treatments are a nice touchy feely way of creating a placebo generated improvement – and those that go on to develop chronicity have some barrier to the effects of placebo, perhaps their ego is eased when they finally receive physical therapy if not their actual symptoms. I’m sorry I have rambled and I’m not sure even that I have made a point – just typing as I think in response to this stimulating blog!

  35. John Quintner says:

    Thanks for your efforts, Georgie. But I still cannot go along with the untestable theory propounded by Dr Sarno. However the results of his educational programme certainly do seem to be impressive.

    I suggest that these positive outcomes can be attributed to the powerful influence of contextual factors, much along the lines of the highly popular “rest cure” for neurasthenia in the late 19th century, pioneered by the great American neurologist, Silas Weir Mitchell.

  36. Hi Georgie
    We’re having a look at what happened. For some reason your comments were filtered before they arrived at the moderation stage.
    We are trying to retrieve them now.
    Heidi

  37. Neil O'Connell says:

    Hi Ruth,

    You raise interesting points relating to external validity. However we need to be careful drawing the conclusioon that the single session of advice was effective. The lack of a waiting list or no treatment control group leaves wide open the possibility that neither intervention helped at all and the change we observe is simply the natural course of the symptoms.

    I am not entirely convinced that in a different population with different needs either model of care might be more effective.

  38. Neil O'Connell says:

    Clare:

    Hello you!

    To be clear its not my trial – I had nothing to do with it – just blogging on it.

    We are not really very far along with useful clinical predictors. Where there is no overall effect there is unlikely to be a specific subgroup of responders. Consider that for there to be a subgroup of responders, there would also have to be an equal sized subgroup that the intervention actively made worse in order for the average effect size to be nil.

    Don’t be disappointed – this information potentially allows you to relieve yourself of ineffective treatment strategies.I reckon thats a positive thing.

  39. Neil O'Connell says:

    Hi Georgie,

    Sorry you’ve been having problems. At least, by virtue that this comments has posted OK it now looks as though you can post comments.

    Best

    Neil

  40. Neil O'Connell says:

    Thanks Neil,

    Who knows – the edicational booklet does not spend much time on tissues though the exercises are at least partially oriented in that way: http://www.maic.qld.gov.au/injury-management/whiplash-injury-recovery.shtml

    Still its a fair indication thart this particular approach is not helpful and that is a usefuyl thing.

  41. Neil O'Connell says:

    Hi Jukka,

    Not much on cognitive or pain ed – just this booklet which is quite broad: http://www.maic.qld.gov.au/injury-management/whiplash-injury-recovery.shtml

    I believe they would have excluded grade 3 as there are signs of specific pathology – i.e. nerve root compromise.

  42. Ruth White says:

    Hi Neil

    Thanks for sharing. I read the population info with interest. Certainly a single dose of advice seems effective if you’re well off, live in a City, have an insurer to pay for your treatment, are proficient in written and spoken English, generally don’t take opioids, have a job and have a degree. This study population seems to be in stark contrast to those seen in public health clinics (NSW) so for those managing different populations eg for those low/lower health literacy a single advice session may not be enough to achieve meaningful change in health outcomes, particularly if depressed and sleep deprived when receiving the ‘dose’.

  43. This can’t be about content or including urls, because I have neither! I give up apart from to say this study is helpful PMID: 21419349 and further info can be found at the TMS wiki site.

  44. Briefly, yes there is growing evidence now John and a real movement to raise awareness of the concept that chronic pain is not due to an ‘abnormality’, but is due to learned nerve pathways and created/driven by the brain and nervous system. Once this is recognized and accepted by the patient, full recovery is possible by helping them identify the links and triggers and deal with the underlying emotional cause, often with little intervention from a health professional.

    The tmwiki.org site is a great resource for this work and apart from SIRPA in the UK/Europe, the US now have the ppdassociation.org, run by the Specialists there. Howard Schubiner MD is the person to speak to about current research into this field, which he is leading.

    Otherwise, this study also supports the concept, if only by raising questions about the current beliefs about chronic back pain. PMID: 21419349

    I hope that helps?

  45. Oh well, let’s try again.

    I understand what you mean John because Dr Sarno himself did not do any robust studies, just case series, although he did have the most remarkable results. I visited him in 2007 after not only resolving my own recurring health problems by following the recommendations in his books, but numerous patients I supported as they followed the advice had life-changing results, hence my need to find out more. This resulted in a major turnaround in my own career.

    Since that time there has been a massively growing ‘movement’ to raise the profile of this concept as well as build an evidence-base, so that it doesn’t rely purely on ‘hypotheses’.

    We have so far had 4 conferences in the US and there is a huge amount of information about this work online these days. The main organisations are the non-profit PPDAssociation.org in the US which is run by the main Specialists over there and SIRPA here in the UK/Europe. There is also the TMSwiki.org site which is a huge resource for anyone looking to find information, whether that is about Dr Sarno’s core work, or the work that has developed over the past 6 years or so among those of us who are passionate about this concept and approach.

  46. Since yesterday I have tried unsuccessfully to upload a comment and it doesn’t even tell me it has gone to moderation. Any suggestions please if this gets through?

  47. I struggled to upload another comment yesterday, but here goes again.

    I understand what you mean John because Dr Sarno himself did not do any robust studies, just case series, although he did have the most remarkable results. I visited him in 2007 after not only resolving my own recurring health problems by following the recommendations in his books, but numerous patients I supported as they followed the advice had life-changing results, hence my need to find out more. This resulted in a major turnaround in my own career.

    Since that time there has been a massively growing ‘movement’ to raise the profile of this concept as well as build an evidence-base, so that it doesn’t rely purely on ‘hypotheses’.

    We have so far had 4 conferences in the US and there is a huge amount of information about this work online these days. The main organisations are the non-profit PPDAssociation.org in the US which is run by the main Specialists over there and SIRPA here in the UK/Europe. There is also the TMSwiki.org site which is a huge resource for anyone looking to find information, whether that is about Dr Sarno’s core work, or the work that has developed over the past 6 years or so among those of us who are passionate about this concept and approach.

    Apart from the numerous studies demonstrating the lack of correlation between pain and spinal degeneration, the following article demonstrates the lack of correlation between pain, posture and biomechanics. PMID: 21419349

    Howard Schubiner MD is one of the Specialists in the US who has been undertaking studies in this field and you can find out more about that on his own website (unlearnyourpain.com), although it is still quite early days. He also includes dozens of studies in his own book, whether that’s based on the neurophysiology, the links between childhood trauma and chronic pain, whiplash studies etc.

    I hope this information answers your question. Certainly in my experience, although there might be little difference in the actual approach from some other educational and self-empowering approaches for chronic pain/whiplash, the lynch-pin between ‘management’ and ‘cure’ is based on the health professional and the patient accepting that the pain is not due to a physical ‘problem’ (that could get worse), but is psychophysiological, which can be reversed.

  48. Hi Neil
    As a clinician ( we even worked together at tommies 🙂 I’m a bit gutted about the results of your study. However I will certainly be more cautious of over treating the problem. I haven’t read your study but do u think there are any pertinent clinical indicators -subjective or objective -which might be more influential as to whether treatment will be effective or not ? C

  49. Neil Pearson says:

    Thanks for reporting on this Neil. The results make me wonder about many things, including the possible, implicit message provided to the participants in this study by the intervention. Did they think that the intervention was ‘treatment of their physical tissues’. Who knows, it might have been an explicit message provided to them as well by the PTs. It’s purely hypothesis here, yet if pain (and disability) is something more than directly related to tissue injury, and we have some evidence that pain beliefs can be barriers to recovery, when we provide treatment with a primary focus on fixing the tissues, there’s a chance that this intervention will convince the person in pain that their pain is a symptom directly related to tissue injury or abnormality.
    As one possible answer to how this study directs clinical practice – if you believe that pain is a complex, biopsychosocial experience, and know that there is evidence that shows how tissue pathology education can hinder patient outcomes, then consider providing advice and interventions that do more than focus on the tissues, and that are inconsistent with both unhelpful pain beliefs and attitudes to recovery.
    Further research might show that initial pain science education isn’t so helpful if the subsequent treatment contradicts its messages.

  50. Jukka Aho says:

    One might assume that if you try it all, then something might stick – but apparently not. Seems like a well conducted study, although I haven’t gotten to read the full article… However, two things I’d like to ask incase you have the answers;
    a) did they include cognitive aspects and pain education to the intervention as well?
    b) why did they only use WAD 1 and 2 patients and not the full range of WAD populations?

  51. John Quintner says:

    Georgie, can you produce any evidence to support your claim? I found Dr Sarno’s theories to be highly speculative at the time he announced them and I was not aware that this situation had changed since then.

  52. Neil O'Connell says:

    Don – thanks.

    Stuart – I only have the information available in the published paper.

    John, Not a silly question. To my mind how it should inform practice is by leading to substantially reduced intervention (at least with regards exercise therapies) – thorough assessment, good advice and education may be the best we can do. I suspect that less than that confers risk of missing significant injury. Maybe that triage role is the most useful part of the interaction.

    How it will inform practice is quite another thing. I suspect PTs will find it very difficult to do so little actual treatment, particularly with a treatment approach that is commonly perceived as only ever being a “good thing”.

  53. Georgie Oldfield says:

    As a Physiotherapist whose understanding and treatment of chronic pain (including whiplash) has changed dramatically, these results don’t surprise me. In the past 7 years my own specialism has evolved from the work of John E Sarno MD, now retired Prof of Rehabilitation Medicine at the Rusk Institute in New York.

    The concept on which our work is based is that chronic whiplash is frequently not due to any physical cause (after any initial tissue trauma has healed, if present) and is not just affected by stress/emotions, but it triggered by them and then ‘driven by’ the brain and nervous system when it becomes conditioned.

    Once this is recognised (and accepted) and the underlying causes addressed, full recovery is possible because the learned nerve pathways can be reversed. This is about helping people recognise the links and triggers for their pain, then enabling them to use self-empowering strategies, which often brings about life-changing results.

    My hope is that with the work of myself, those I train and the other Specialists in this field, the awareness of this will not just help people who are already suffering from chronic pain, but enable people to prevent it in the first place.

  54. John Quintner says:

    Neil, I know it is probably a silly question but I must ask it nevertheless. How do you see the results of this obviously important study informing clinical practice?

  55. stuart miller says:

    Neil,
    Thanks for a very comprehensive review – I know that traumatic brain injury was mentioned as exclusion – how was this determined ? Did it include post-concussion ? I couldn’t find anything in the article. As well, it looks like the assessment / evaluation measures were extensive (including PCS). Was there any measure of perceived injustice (IEQ – Injustice Experiences Questionnaire) ? Mick Sullivan’s work (including PCS and IEQ) at McGill has been helpful for my understanding. Thanks again.

  56. Don Solomon says:

    Dear Neil,
    Congratulations on a very informative article. I look forward to reading the full text version myself.