Multimodal / Physiotherapy Treatment

Rating

Category: Allied Health Options

Injury Type: Acute

What is it?

Multimodal treatment involves the combination of several different types of treatment, usually within the one treatment session. In relation to whiplash, multimodal treatment may include any of the following: active movement; strengthening exercises; muscle re-education; kinaesthetic exercises, posture correction; functional exercises; manual therapy such as manipulation, mobilisation and massage; electrotherapy; advice; education; home exercise programme; medication; and soft collar. Therefore, multimodal treatment is a combination of more than one of these types of treatment.

How does it work?

It is thought that there are various factors that can potentially influence the development and continuation of symptoms after whiplash. Aside from the physical forces involved in causing a whiplash injury, other related factors may include, but are not limited to: physical; psychological and socio-demographic factors. Therefore, the aim of a multimodal treatment programme is to address as many of these potential underlying factors as possible in order to achieve the best outcome. There may also be an increased benefit from providing multiple treatments in conjunction with each other compared to providing those treatments individually.

Is it effective?

There is some evidence to suggest that multimodal treatment is likely to be more effective than providing individual treatments in isolation.

A systematic review found that 'multimodal care' consisting of manipulation and mobilisation was not more effective than a placebo at improving pain and function in people with chronic neck pain. However, it may be marginally more effective than no treatment for people with chronic neck pain and headaches. Manipulation and/or mobilisation in conjunction with other physical medicine agents was not found to be any better than various other treatments including no treatment, placebo tablets, exercise, combined treatments, collar, electrotherapy, and massage.

There is strong evidence for multimodal treatment programmes that include manipulation, mobilisation and an exercise focus. The programmes may also have included medication, heat/cold therapy and education. It is not clear if exercise is the most important 'ingredient'. A recent systematic review of 11 scientific studies found strong evidence supporting the use of multimodal programs in the period between 2 and 12 weeks following whiplash injury. Two recent studies have compared different combinations of treatments to either 'standard care' (wearing a collar and taking anti-inflammatory medication) or an education booklet and home exercise programme. Both these studies found the multimodal treatment was the most effective up to a few months after a whiplash injury.

A systematic review and meta-analysis of randomised controlled trials, which included 21 studies and found that for patients with an acute / subacute whiplash injury (Grade 2), active physiotherapy was more effective in the short term at reducing pain and increasing range of motion of the neck when compared with standard intervention such as a collar or routine GP care. It also found that specific physiotherapy interventions such as manipulation, kinesiotaping, magnetic therapy led to a short term decrease in pain.

The results of a large randomised controlled trial suggest that when dealing with patients who have persisting symptoms within the first six weeks of injury, a six session physiotherapy treatment package provided more benefit than a single physiotherapy advice session in reducing short term neck related disability. Due to the number of treatments provided, the authors conclude that the physiotherapy care package was not a cost effective method of managment.

Are there any disadvantages?

There is no evidence to suggest that there are disadvantages associated with multimodal treatment, however potential side effects of each individual treatment should be considered. It is important that the treatment is provided by a qualified professional and that an appropriate assessment is carried out prior to treatment.

Where do you get it?

Multimodal treatment is commonly provided by physiotherapists. Doctors, chiropractors and osteopaths may also provide multimodal treatment.

Recommendations

Treatment consisting of more than one approach, i.e. multimodal, may be more effective than individual treatments provided in isolation. It should consist of at least manipulation and/or mobilisation and some form of exercise. Multimodal treatment should be based on an individual assessment and provided by a qualified professional.

Key References

  • Gross, AR, Hoving, JL, Haines, TA, Goldsmith, CH, Kay, T, Aker, P, Bronfort, G, Cervical overview group, ‘Manipulation and mobilization for mechanical neck disorders’, Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004249. DOI:10.1002/14651858.CD004249.pub2.
  • Hurwitz, E, Carragee, E, Van der Velde, G, Carroll, L, Nordin, M, Guzman, J, Peloso, P, Holm, L, Coˆte, P, Hogg-Johnson, S, Cassidy, D & Haldeman, S 2008, ‘Treatment of neck pain: non invasive interventions; results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders’, European Spine Journal, vol. 17, no. 1, pp. 123-152.
  • Jull G, Kenardy, J, Hendrikz J, Cohen M & Sterling, M 2013, ‘Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments’, Pain, vol. 154, pp. 1798–1806.
  • Jull, G, Sterling, M, Kenardy, J & Beller, E 2007, ‘Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? A preliminary randomized controlled trial’, Pain, vol. 129, no. 1-2, pp. 28-34.
  • Lamb, SE, Gates, S, Williams, MA, Williamson, EM, Mt-Isa, S, Withers, EJ, Castelnuovo, E, Smith, J, Ashby, D, Cooke, MW, Petrou, S & Underwood, MR 2013, ‘Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial’, Lancet, vol. 381, pp. 546–56.
  • Leaver, AM, Refshauge, KM, Maher, CG & McAuley, JH 2010, ‘Conservative interventions provide short-term relief for non-specific neck pain: a systematic review’, Journal of Physiotherapy, vol. 56, pp. 73-85.
  • 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.
  • Miller, J, Gross, A, D'Sylva, J, Burnie, SJ, Goldsmith, CH, Graham, N, Haines, T, Brønfort, G & Hoving, JL 2010, ‘Manual therapy and exercise for neck pain: A systematic review’, Manual Therapy, vol. 15, pp. 334-354.
  • Poorbaugh, K, Brismée, J, Phelps, V & Sizer, P 2008, ‘Late whiplash syndrome: a clinical science approach to evidence-based diagnosis and management’, Pain Practice, vol. 8, no. 1, pp. 65-89.
  • Rushton, A, Wright, C, Heneghan, N, Eveleigh, G, Calvert, M & Freemantle, N 2011, ‘Physiotherapy rehabilitation for whiplash associated disorder II: a systematic review and meta-analysis of randomised controlled trials’, British Medical Journal, vol. 1, pp. 1-13.
  • Vassiliou, T, Kaluza, G, Putzke, C, Wulf, H & Schnabel, M 2006, ‘Physical therapy and active exercises – An adequate treatment for prevention of late whiplash syndrome? Randomized controlled trial in 200 patients’, Pain, vol. 124, no. 69-76.
  • Yadla, S, Ratliff, J & Harrop, J 2008, ‘Whiplash: diagnosis, treatment, and associated injuries’, Current Reviews in Musculoskeletal Medicine, vol. 1, pp. 65-68.
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