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Sterling M1, Kenardy J2, Smeets R3, Keijzers G4, Warren J1
1The University of Queensland, RECOVER Injury Research Centre, Brisbane, Australia, 2The University of Queensland, Brisbane, Australia, 3Maastricht University, Maastricht, Netherlands, 4Gold Coast University Hospital, Emergency Medicine, Gold Coast, Australia
Background: Whiplash Associated Disorder (WAD) is a common and costly health burden. Current treatments for acute WAD have failed to decrease the proportion of patients who develop chronic pain and disability. One reason may be that treatments have been non-specific, have taken a biomedical approach and have not targeted identified modifiable risk factors. Acute symptoms of post-injury stress predict poor recovery at long term follow-up and may contribute to the development and maintenance of pain.
Purpose: The aim of this study was to investigate the effectiveness of stress inoculation training integrated with standard physiotherapy exercise and delivered by physiotherapists (StressModex) compared to standard physiotherapy exercise alone in patients with acute WAD.
Methods: A randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis was conducted in 108 participants with acute WAD (Grades II, 4 weeks post injury) and at risk of poor recovery based on a validated predictive screening tool. Participants were recruited from hospital Emergency Departments and primary care. The intervention group (StressModex) received a 6 week program of combined physiotherapy exercise and a cognitive behavioural approach that teaches general problem solving coping strategies to manage stress-related anxiety (i.e. relaxation training, cognitive restructuring and positive self-statements) and provides information about the impact of stress on physical and psychological well-being. The control group received a 6 week program of physiotherapy exercise only. Both interventions were delivered by physiotherapists. The primary outcome was the Neck Disability Index (NDI). Secondary outcomes included pain (NRS), Global Perceived Effect (GPE), posttraumatic stress symptoms (PDS), pain catastrophising (PCS), pain self-efficacy and depression, anxiety, stress (DASS). Outcomes were taken at baseline, 6 weeks, 6 months and 12 months post-randomisation. Analysis was intention to treat and treatment effects were calculated using linear mixed models. Alpha was set at p=0.05. anzctr.org: ACTRN12614001036606.
Results: Of the 108 randomised participants (mean age 41.3 years, 62% female), 102 (94.4%) completed the 6 week follow-up, 98 (90.7%) the 6 month follow-up and 98 (90.7%) the 12 month follow-up. The stress inoculation training and exercise intervention was more effective than exercise alone for pain related disability at all follow-up points. At 6 weeks, the treatment effect on the 0-100 NDI was -10 (95% CI - 15.5 to -9.0), at 6 months was -7.8 (95% CI -13.8 to -1.8), and at 12 months was -10.1 (95% CI -16.3 to -4.0). A significant benefit of the stress inoculation and exercise intervention was found for some secondary outcomes (stress, depression, pain self-efficacy and global perceived recovery).
Conclusion(s): A 6 week-program of physiotherapist led stress inoculation training combined with exercise (StressModex) shows clinically worthwhile effects on pain related disability, pain, stress and perceived recovery over physiotherapy exercise alone. Physiotherapists can successfully deliver a psychological intervention combined with exercise to improve health outcomes after acute whiplash injury.
Implications: Physiotherapists are the most commonly used practitioner delivering care to patients with acute WAD and with some additional training, this approach to early management could be considered for all whiplash injured patients at risk of poor recovery.
Keywords: whiplash associated disorders, post-injury stress, physiotherapy
Funding acknowledgements: Funding for the study was received from the National health and Medical Research Council of Australia (NHMRC) APP 1069443.
Purpose: The aim of this study was to investigate the effectiveness of stress inoculation training integrated with standard physiotherapy exercise and delivered by physiotherapists (StressModex) compared to standard physiotherapy exercise alone in patients with acute WAD.
Methods: A randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis was conducted in 108 participants with acute WAD (Grades II, 4 weeks post injury) and at risk of poor recovery based on a validated predictive screening tool. Participants were recruited from hospital Emergency Departments and primary care. The intervention group (StressModex) received a 6 week program of combined physiotherapy exercise and a cognitive behavioural approach that teaches general problem solving coping strategies to manage stress-related anxiety (i.e. relaxation training, cognitive restructuring and positive self-statements) and provides information about the impact of stress on physical and psychological well-being. The control group received a 6 week program of physiotherapy exercise only. Both interventions were delivered by physiotherapists. The primary outcome was the Neck Disability Index (NDI). Secondary outcomes included pain (NRS), Global Perceived Effect (GPE), posttraumatic stress symptoms (PDS), pain catastrophising (PCS), pain self-efficacy and depression, anxiety, stress (DASS). Outcomes were taken at baseline, 6 weeks, 6 months and 12 months post-randomisation. Analysis was intention to treat and treatment effects were calculated using linear mixed models. Alpha was set at p=0.05. anzctr.org: ACTRN12614001036606.
Results: Of the 108 randomised participants (mean age 41.3 years, 62% female), 102 (94.4%) completed the 6 week follow-up, 98 (90.7%) the 6 month follow-up and 98 (90.7%) the 12 month follow-up. The stress inoculation training and exercise intervention was more effective than exercise alone for pain related disability at all follow-up points. At 6 weeks, the treatment effect on the 0-100 NDI was -10 (95% CI - 15.5 to -9.0), at 6 months was -7.8 (95% CI -13.8 to -1.8), and at 12 months was -10.1 (95% CI -16.3 to -4.0). A significant benefit of the stress inoculation and exercise intervention was found for some secondary outcomes (stress, depression, pain self-efficacy and global perceived recovery).
Conclusion(s): A 6 week-program of physiotherapist led stress inoculation training combined with exercise (StressModex) shows clinically worthwhile effects on pain related disability, pain, stress and perceived recovery over physiotherapy exercise alone. Physiotherapists can successfully deliver a psychological intervention combined with exercise to improve health outcomes after acute whiplash injury.
Implications: Physiotherapists are the most commonly used practitioner delivering care to patients with acute WAD and with some additional training, this approach to early management could be considered for all whiplash injured patients at risk of poor recovery.
Keywords: whiplash associated disorders, post-injury stress, physiotherapy
Funding acknowledgements: Funding for the study was received from the National health and Medical Research Council of Australia (NHMRC) APP 1069443.
Topic: Musculoskeletal; Pain & pain management
Ethics approval required: Yes
Institution: The University of Queensland
Ethics committee: Human Ethics Committee
Ethics number: 2011000206
All authors, affiliations and abstracts have been published as submitted.
