Psychology (in combination with other rehabilitation)

Rating

Category: Allied Health Options

Injury Type: Acute/Chronic

What is it?

There are many treatment techniques which are used as part of psychological management. Cognitive behaviour therapy, or CBT, is the technique most commonly used in relation to whiplash injury. CBT involves learning from a therapist how to overcome the distorted, negative thinking patterns that can accompany chronic whiplash injuries. Cognitive behaviour therapists may also use other techniques to encourage the person to do more things that give them pleasure, helping them to solve problems in their life, and learning better social skills. CBT and other psychological and psychosocial treatments may also be used in combination with other conservative treatments such as Physiotherapy.

How does it work?

People with whiplash often complain of impaired cognitive function, such as memory, attention problems, anxiety and even depression. Inappropriate thought processes about pain may lead to pain catastrophizing (increased pain response), reduced physical activity and ultimately lead to a development of prolong pain and disability. Consequently stress may result from disruption to work and social life activities and lead to sleep and ongoing depressive problems and inappropriate coping behaviour. In cognitive behaviour therapy, distorted thinking is challenged by the therapist who teaches the person how to change their thinking patterns in everyday life. Other forms of psychosocial interventions also aim to increase daily involvement in goal-directed activity and minimize psychosocial barriers to other treatments.

Is it effective?

There are studies which show that people with long term whiplash get benefit from psychological/psychosocial interventions when used in combination with other treatments such as Physiotherapy. This findings are based on good quality evidence which suggests that interventions such as CBT and the Progressive Goal Attainment Program (PGAP), when used in conjunction with Physiotherapy and rehabilitation improves cognitive function, reduces pain and sick leave and also helped people return to work. A recent systematic review concluded that referral to Psychology is indicated if a patient is showing no signs of improving at 3-4 weeks following whiplash injury. Another recent systematic review found strong evidence supporting the use of a multimodal treatment approach which included Psychology in the management of acute and chronic whiplash.

A recent study looked at the effect of CBT as an adjunct to infiltration (local anaesthetic injection), medication, or physiotherapy in the management of whiplash (6-12 months post-injury) and found that CBT improved pain intensity and working ability in these patients. A recent small pilot randomised controlled trial investigated the effects of CBT in the management of post-traumatic stress disorder (PTSD) associated with chronic WAD. The findings from this study indicate that CBT may be effective to target PTSD symptoms in people with chronic WAD. This study also found that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds. The findings from this study hightlight the complex and interrelating mechanisms that may underlie both WAD and PTSD and show that CBT can translate into improving the physical and mental impairments associated with whiplash.

Another randomised controlled trial found evidence that individualised multidisciplinary treatment including management with physiotherapy, psychology and medical attention by a doctor does not help reduce the incidence of chronicity in patients with acute whiplash (less than four weeks follwoing injury) when compared with usual care.

Are there any disadvantages?

Psychological/psychosocial treatments will involve seeing therapists weekly for several months. It can be expensive, although in Australia, Medicare now provides rebates for visits to Clinical Psychologists, Physiotherapists and Occupational Therapists.

Where do you get it?

Psychological/psychosocial treatments are generally provided by a specially trained Clinical Psychologist or Counsellor. These days many Physiotherapists and Occupational Therapists work with Psychologists, or have some specific training in this field. In Australia, Medicare now provides rebates for visits to Clinical Psychologists, Physiotherapists and Occupational Therapists, under the recent Better Access to Mental Health Care scheme. Some of these treatments may also be covered by some private health insurance funds and is sometimes available from therapists employed in hospitals or government-funded clinics.

Recommendations

There is some evidence that psychological/psychosocial treatments in conjunction with other rehabilitation treatments are useful for people with chronic whiplash, but more high quality research is needed.

Key References

  • Dunne, RL, Kenardy, J & Sterling, M 2012, ‘A randomized controlled trial of cognitive-behavioral therapy for the treatment of PTSD in the context of chronic whiplash’, Clinical Journal of Pain, vol. 28, pp. 755–765.
  • Leach, J 2007, ‘Editorial comment on ‘developing clinical guidelines for the physiotherapy management of whiplash associated disorder (WAD)' by C. Mercer, A. Jackson and A. Moore’, International Journal of Osteopathic Medicine, vol. 10, no. 2-3, pp. 55.
  • 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.
  • Pato, U, Stefano, GD, Fravi, N, Arnold, M, Curatolo, M, Radanov, BP, Ballinari, P & Sturzenegger, M 2010, ‘Comparison of randomized treatments for late whiplash’, Neurology, vol. 74, pp. 1223–1230.
  • Seferiadis A, Rosenfeld M & Gunnarsson R 2004, ‘A review of treatment interventions in whiplash-associated disorders’, European Spine Journal, vol. 13, pp. 387–397.
  • Sterling, M & Kenardy, J 2008, ‘Physical and psychological aspects of whiplash: important considerations for primary care assessment’, Manual Therapy, vol. 13, no. 2, pp. 93–102.
  • Sullivan, MJL, Adams, H, Rhodenizer, T & Stanish WD 2006, ‘A Psychosocial Risk Factor – Targeted Intervention for the Prevention of Chronic Pain and Disability Following Whiplash Injury’, Physical Therapy, vol. 86, no. 1, pp. 8-18.
  • 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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