Act As Usual

Rating

Category: Allied Health Options

Injury Type: Acute/Chronic

What is it?

Act as usual is a strategy which encourages people with whiplash, especially in the early stages, to continue staying as active as possible within tolerable levels. Encouraging people to stay active and continuing with their normal lives is seen as a means of facilitating normality and participation in activities of daily living during the recovery period. This may be undertaken in a structured manner (check-list based information covering various aspects about whiplash) or in an unstructured conversational manner with a health professional.

How does it work?

It is thought that by encouraging normal activities the emphasis is taken away from the injury itself. Physiologically, it is thought that normal movement patterns may have a positive effect on symptoms of whiplash, such as muscle spasm and pain. Educating people with whiplash about pain behaviours (such as focussing on pain which can enhance pain perception) also helps to prevent the development of 'fear avoidance' behaviours in the future.

Is it effective?

There is some high level evidence to suggest that acting as usual, subsequent to whiplash, does lead to certain positive outcomes. Based on the results of a systematic review the authors recommended that people in the early stages following whiplash should be advised to "act as usual" and engage in early, controlled, physical activity to tolerable levels.

Two randomised controlled trials have compared acting as usual to other forms of treatments such as collars and active interventions. Both studies included patients immediately after their whiplash injuries and reported on short term and long term outcomes. The results from both these studies indicate that all patients improved over time. However, in one of the studies, which measured results for six months after whiplash, people who acted as usual were much better compared to people who wore collars and had time off work. This was particularly noticeable for pain, headaches, stiffness in movement, concentration and memory. In a recent study at the one year mark, there was no difference in outcomes for any of these treatments.

However a recent systematic review found strong evidence supporting the practice of encouraging people to act as usual as soon as possible following whiplash injury. A low-quality study investigating the recommendation "act as usual", in combination with non-steroidal anti-inflammatory (NSAIDS) medications found that this combination was sufficient for management of patients with Grade 1 (neck pain but no restriction in neck movement or neck tenderness), based on the classification system of the Quebec Task Force (QTF). Based on these findings, the authors of this study state that for patients presenting with whiplash Grade I, there may be no need for any physical therapy.

Are there any disadvantages?

While there were no reported disadvantages or side effects from act as usual, this treatment should be prescribed and monitored by a health professional at regular intervals. If patients' symptoms are not improving with this approach, health professionals need to review their management plan.

Where do you get it?

Advice to act as usual can be provided by any appropriately qualified health professional including doctors, nurses, physiotherapists and chiropractors.

Recommendations

While there is some evidence to support advice to act as usual within tolerable levels, especially in the early stages, more research is needed to describe its effect in the long term.

Key References

  • Borchgrevink, GE, Kaasa, A, McDonagh, D, Stiles, T, Haraldseth, O & Lerein, I 1998, 'Acute Treatment of Whiplash Neck Sprain Injuries: A Randomized Trial of Treatment During the First 14 Days After a Car Accident', Spine, vol. 1, no. 23, pp. 25-31.
  • Dehner, C, Elbel, M, Strobel, P, Scheich, M, Schneider, F, Krischak, G & Kramer, M 2009, 'Grade II whiplash injuries to the neck: what is the benefit for patients treated by different physical therapy modalities?', Patient Safety in Surgery , vol. 3, no. 2, doi: 10.1186/1754-9493-3-2.
  • Dehner C, Kraus, M, Scholl, H, Schneider, F, Richter, P & Kramer M 2012, 'Therapy recommendation "act as usual" in patients with whiplash injuries, Q'TFI°', Global Journal of Health Science, vol. 4, no. 6, pp. 36-42.
  • Guzman, J, Haldeman, S, Carroll, L, Carragee, E, Hurwitz, E Peloso, P, Nordin, M, Cassidy, D, Holm, L, Coˆte, P, Van der Velde, G & Hogg-Johnson, S 2008, 'Clinical practice implications of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders; from concepts and findings to recommendations', European Spine Journal, vol. 17, no. 1, pp. 199-213.
  • Kongsted, A, Qerama, E, Kasch, H, Bendix, T, Winther, F, Korsholm, L & Jensen TS 2007, 'Neck Collar, "Act-as-Usual" or Active Mobilisation for Whiplash Injury? A Randomised Parallel-Group Trial', Spine, vol. 32, no. 6, pp. 618-626.
  • Mercer, C, Jackson, A & Moore, A 2007, 'Developing clinical guidelines for the physiotherapy management of whiplash associated disorder (WAD)', International Journal of Osteopathic Medicine, vol.10, no. 2-3, pp. 50-54.
  • Seferiadis A, Rosenfeld M & Gunnarsson R 2004, 'A review of treatment interventions in whiplash-associated disorders', European Spine Journal, vol. 13, pp. 387–397.
  • Verhagen, A, Scholten-Peeters, G, Van Wijngaarden, S, De Bie, R & Bierma-Zeinstra, S 2007, 'Conservative treatments for whiplash', Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD003338. DOI: 10.1002/14651858.CD003338.pub3.
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