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The Effect of Neck Proprioceptive Exercise on Recovery from Cervical Whiplash-Associated Disorders (WAD) Coffey, Nicole; Melo, Joseph; Wnuk, Kathryn; Wong, Jessie; Zenone, Antonio 2011-08

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The Effect of Neck Proprioceptive Exercise on Recovery from Cervical Whiplash-Associated Disorders (WAD)  Nicole Coffey, Joseph Melo, Kathryn Wnuk, Jessie Wong, Antonio Zenone   Supervisor: Marj Belot Outline ? Background ? Rationale ? Search Methods ? Results ? Discussion ? Implications for Research and Practice Background ? Whiplash-associated disorders (WAD) ? A collection of signs and symptoms attributed to acceleration and deceleration forces experienced in motor vehicle accidents and other neck trauma   ? 50% of WAD patients continue to have neck symptoms one year post injury (Carroll et al., 2008)  ? Account for extensive social and economic costs (Sterling et al., 2006) Whiplash-Associated Disorder (WAD) Classification System Quebec Task Force  Classification Grade Clinical presentation  0 No complaint about neck pain  No physical signs I Complaint of pain, stiffness or tenderness only  No physical signs  II Neck complaint Musculoskeletal signs including:     Decreased range of movement      Point tenderness III Neck complaint Musculoskeletal signs  Neurological signs including:      Decreased or absent deep tendon reflexes    Muscle weakness    Sensory deficits IV Neck complaint and fracture or dislocation   (Spitzer et al., 1995)  Knowledge Gap  ? Despite the high incidence of WAD, there is no known gold standard rehabilitation intervention strategy by which to guide treatment                  (Ask et al, 2009), (Sarig-Bahat, 2003),(Cote et al., 2009),(Hurwitz et al., 2008)  Common Signs and Symptoms of WAD I and II  ? Hyperalgesia, movement loss, posttraumatic stress symptoms and varying levels of pain and disability  (Sterling and Kenardy, 2008)  ? Alterations in sensorimotor function (Treleaven, 2003) Background Rationale  ?  The impairment in orienting the head in space is analogous to joint position deficits documented in the extremities post-injury  (Loudon et al., 2008, Cooper at al. 2005)   ? Reasonable to hypothesize that proprioceptive training would result in reduced impairment and improved function in those with cervical dysfunction.   Research Question  Do cervical proprioceptive exercises, alone or in conjunction with other therapeutic interventions, effectively reduce perceived pain and improve physical functional ability in adults with whiplash-associated disorder (WAD) I and II?  Search Strategy Electronic databases ? MEDLINE (OvidSP) ? CINAHL, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, and PEDro Grey literature ? Papers First, Proceedings First, Dissertations and Thesis, Government statistics Reference lists Table of contents of pertinent publications  ? Spine, Journal of Manipulative & Physiological Therapeutics, Clinical Rehabilitation Clinical experts  Search Methods ? Electronic databases were searched from their inception until May 2011 including:  ? MEDLINE, CINAHL, EMBASE, CENTRAL, SPORTDiscus, PEDro, and the Cochrane Database of Systematic Reviews   ? Subsequent searches were conducted every 4 months from July 2010 to May 2011. Medical subject heading (MeSH) terms in the initial search included: ? ?whiplash injuries,? ?neck injuries,? ?cervical vertebrae,? ?neck muscles,? ?exercise,? ?posture,? ?proprioception,? and ?stabilization?   Full text screened (n=30)   Abstracts identified (n=1907)   RCT included in systematic review (n=4)   Publications excluded after screening the abstract (n=1877)  Excluded after reading the full text (n=26)  Search Methods ? Search strategy results based on titles and abstracts were screened by two independent reviewers for relevance and accordance with inclusion criteria   ? Inclusion criteria consisted of criteria such as  articles written in English that involved adult participants with WAD I, II, or III   ? Applicable full text articles were then reviewed Study Characteristics ? Types of Studies ? Randomized controlled trials (RCT) written in English  ? Clinical controlled trials would have been considered, but none met the inclusion criteria   ? Types of Participants ? Adults age 18 and over diagnosed with either acute, subacute, chronic WAD I or WAD II Study Characteristics ? Types of Interventions ? Cervical proprioceptive exercise as a sole treatment or as an adjunct to a multimodal intervention   ? Types of Outcome Measures ?  Pain ? Neck Pain Index, Visual Analog Scale ? Neck Functional Ability ? Neck Disability Index, Pain Disability Index Inclusion Criteria Title/Abstract ? Patients included in the study suffer from whiplash-associated disorder  (WAD I, II or III) ? Treatment for whiplash includes a neck exercise intervention ? Outcome measures include pain or functional ability ? Patients involved in this study are adults 19+ ? Study Design: randomized control trial, clinical control trial, or cohort study  Full Text ? Treatment intervention must include neck proprioceptive exercise   Exclusion Criteria Title/Abstract ? WAD  IV ? The paper is not written in English  Full Text ? Intervention not well defined and not able to obtain information from author  Quality Assessment ? At least two independent reviewers assessed study quality   ? Methodological quality was determined using the PEDro scale  ?  Articles with PEDro scores of 6/10 or greater were included in the study   PEDro Scale Criteria 1. eligibility criteria were specified 2. subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received) 3. allocation was concealed -> external randomization service 4. the groups were similar at baseline regarding the most important prognostic indicators -> subjects stratified prior to randomization 5. there was blinding of all subjects 6. there was blinding of all therapists who administered the therapy 7. there was blinding of all assessors who measured at least one key outcome 8. measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups 9. all subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by ?intention to treat? 10. the results of between-group statistical comparisons are reported for at least one key outcome 11. the study provides both point measures and measures of variability for at least one key outcome PEDro Scores 1 2 3 4 5 6 7 8 9 10 11 Total Score Bunketorp et al. (2006) ? ? ? ? ? ? ? ? ? 8/10 Jull et al. (2007) ? ? ? ? ? ? ? ? 7/10 Soderlund et al. (2000) ? ? ? ? ? ? ? ? ? 8/10 Ask et al. (2009) ? ? ? ? ? ? ? ? 7/10 Data Collection and Analysis ? At least two independent reviewers collected data from selected full text articles  ? Information obtained included:  ? study design, purpose of study, participants, comparison groups, and outcome measures Data Synthesis ? A meta-analysis was not feasible for this systematic review  ? Due to the inconsistency of outcome measures utilized by various studies, criteria for homogeneity were not met  Results ? Four trials were selected which studied WAD I and II:  ? Soderlund et al. (2000) ? Acute, 0-6 weeks  ? Bunketorp et al. (2006), Ask et al. (2009) ? Subacute, 6 weeks-3 months  ? Jull et al. (2007) ? Chronic, 3 months-2 years  Soderlund et al. (2000) ? Compared two different home exercise programs for patients with acute WAD ? 3 and 6 month follow-ups ? n=59 ? Average 20 days post-MVA Soderlund et al. (2000) ? Both Groups ? Advice ? Alternating rest with activities ? Keeping the neck from getting cold ? Walking a fair distance every day ? Keeping the upright body posture intact while sitting, standing or walking ? Not to lift or carry heavy items ? Not to remain seated with their head bent forward during the first weeks after the injury Soderlund et al. (2000) ? Both Groups ? Exercise (at least three times a day) ? Looking over each shoulder in turn, 3-5 times ? Moving the arms up and down anteriorly, 2-3 times ? Taking a deep breath and lifting the shoulders upwards, exhaling, and relaxing the shoulders   Soderlund et al. (2000) ? Experimental Group ? Same as control, PLUS an exercise to improve kinaesthetic sensibility (at least three times a day) ? While supine, participants imagined a ?quadrangle? under the head and gently pressed each angle against the floor, followed by the diagonal angles Soderlund et al. (2000) ? Findings ? At 3 and 6 month follow-up ? No significant between group differences on pain VAS and Pain Disability Index ? Significant within group differences relative to baseline for both groups ? Experimental group improved their ?ability to decrease pain?, an item on the Coping Strategies Questionnaire Bunketorp et al. (2006)  ? Evaluated the effects of a supervised physical training program, tailored to meet the needs of patients with subacute WAD versus a home training program ? 3 and 9 month follow-ups ? n=47 ? Average 64 days post-injury Bunketorp et al. (2006) ? Both Groups ? Neck pain pamphlet ? Ergonomic advice ? At least 20 minutes of low-intensity aerobic exercise, twice a week  Bunketorp et al. (2006) ? Intervention Group 1 (Home Exercise) ? Home exercise program to be completed twice a day, with physiotherapist consults available once every two weeks ? Lifting and rolling the shoulders ? Scapular adduction ? Passive cervical rotation ? Rowing exercise using elastic rubber band ? Neck stretches Bunketorp et al. (2006) ? Intervention Group 2 (Supervised Training) ? 60-90 minute physiotherapy sessions, twice a week ? Warm-up on stationary bike ? Cervical rotation over a wedge-shaped pillow ? Supine deep neck flexor exercises (discrete nodding motion) ? Dynamic neck and shoulder exercises ? Functional lifting ? Abdominal and lower extremity strengthening Bunketorp et al. (2006) ? Findings ? At 3 month follow-up ? Statistically significant difference in favour of supervised training on Pain Disability Index and analgesic consumption ? At 9 month follow-up ? No statistically significant difference on all outcome measures between groups ? No statistically significant difference on pain VAS within either group Ask et al. (2009) ? Compared the effect of exercise regimes with focus on either motor control training or endurance/strength training for patients with WAD in subacute phase ? 6 week and 1 year follow-ups ? n=25  Ask et al. (2009) ? Both Groups ? 30 minute one-to-one PT sessions once or twice a week for six weeks ? Minimum 6 sessions, maximum 10 sessions ? Encouraged to perform home exercises and return to common activities as soon as possible Ask et al. (2009) ? Experimental Group 1 (endurance/strength) ? High load recruitment of both superficial and deep neck muscles ? Supine and prone head lifts ? Elastic rubber band resisted cervical flexion, extension, and side flexion in sitting ? Push-ups and dumbbell shoulder exercises Ask et al. (2009) ? Experimental Group 2 (motor control) ? Muscle re-education to reduce synergistic imbalances between the deep and superficial neck muscles  ? Supine craniocervical flexion exercises with progressive holds using an air-filled pressure sensor ? Prone scapular adduction and retraction to train serratus anterior and lower trapezius ? Postural correction exercises ? Low load isometric cervical rotation to train cocontraction of flexors and extensors  Ask et al. (2009) ? Findings ? At 6 weeks and 1 year follow-up ? Clinically important improvement in perceived disability (NDI) and pain VAS in ~50% of participants within each group ? However, no statistically significant differences between groups in either outcome in the short or long term    Jull et al. (2007) ? Questioned whether a multimodal program of physical therapies (MPT) was an appropriate management to be broadly prescribed for chronic WAD II patients versus a self-management program (SMP) ? 10 week pre/post design, no long term follow-up ? n=71 ? Averaged 12-13 months post-MVA  Jull et al. (2007) ? Intervention Group 1 (SMP) ? Provided with a booklet outlining the following: ? Education about the mechanism of whiplash, assurance on recovery and the need to stay active ? Ergonomic advice on activities of daily living, current work practices and work environment ? Description of the exercise program which was to be completed twice a day Jull et al. (2007)  ? Intervention Group 2 (MPT) ? Multimodal program consisting of: ? Same muscle re-education exercises as used by Ask et al. (2009) ? Low velocity mobilising techniques ? Same education as SMP group  Jull et al. (2007) ? Findings ? At 10 weeks ? Statistically significant difference between groups in favour of MPT with regards to perceived pain and disability ? No long term follow-up conducted Current Evidence  ? There is evidence in the literature to support multimodal treatment (Kay et al., 2009),(Miller et al, 2010)  ? There is no consensus regarding ideal treatment protocol for WAD (Miller et al., 2010) Current Evidence  ? Proprioceptive exercise: ? Effective for decreasing subjective pain and disability in chronic neck pain (Sarig-Bahat, 2003)  ? Moderate evidence for long-term benefit for pain and disability in acute and subacute WAD patients (Kay et al., 2009) Findings ? Long-term findings: ? No significant differences between groups  ? Short-term findings: ? Pain disability scores ? Analgesic consumption ? Coping Strategies Questionnaire ? Perceived pain  Challenges ? Not able to isolate source of between-group differences due to multi-modal treatment interventions  ? Unethical to have an experimental group compared to a control group in which no intervention is applied  ? Definitive conclusions cannot be drawn Summary  ? Evidence is inconclusive to determine if proprioceptive exercise is effective at improving pain or functional ability in patients diagnosed with WAD I or II Limitations ? Small sample size ? Non-compliance ? Concurrent treatment ? Unable to perform meta-analysis Implication for Research ? Future studies should apply a standardized treatment ? Including proprioceptive exercise to acute, subacute and chronic populations   ? Experimental and control groups in the studies should be exposed to the same intervention with the exception of the proprioceptive exercise  ? Homogeneity of outcome measures between studies would allow meta-analysis to be conducted Implication for Practice ? A multimodal physiotherapy program, which includes cervical proprioceptive exercise performed under the guidance of a physiotherapist  ? A physiotherapist-supervised exercise program which includes low load deep neck flexor exercises Conclusion ? Active interventions along with proprioceptive exercise improve pain and functional ability in the short term  ? Inconclusive evidence to prove that proprioceptive exercise has any effect on pain and functional recovery  ? Further research is needed to determine if proprioceptive exercise is helpful in the recovery from a whiplash injury References ? Ask, T., Strand, L. I., & Sture Skouen, J. (2009). The effect of two exercise regimes; motor control versus endurance/strength training for patients with whiplash-associated disorders: A randomized controlled pilot study. Clinical Rehabilitation, 23(9), 812-823.   ? Bunketorp, L., Lindh, M., Carlsson, J., & Stener-Victorin, E. (2006). The effectiveness of a supervised physical training model tailored to the individual needs of patients with whiplash-associated disorders--a randomized controlled trial. Clinical Rehabilitation, 20(3), 201-217.   ? Carroll, L. J., Holm, L. W., Hogg-Johnson, S., Cote, P., Cassidy, J. D., Haldeman, S., et al. (2008). Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine, 33(4 Suppl), S83-92.   ? Cooper, R., Taylor, N., & Feller, J. (2005). A systematic review of the effect of proprioceptive and balance exercises on people with an injured or reconstructed anterior cruciate ligament. Research in Sports Medicine, 13(2), 163-178.   ? Cote, J. N., Patenaude, I., St-Onge, N., & Fung, J. (2009). Whiplash-associated disorders affect postural reactions to antero-posterior support surface translations during sitting. Gait & Posture, 29(4), 603-611.   ? Drescher, K., Hardy, S., MacLean, J., Schindler, M., Scott, K., & Harris, S. R. (2008). Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: A systematic review. Physiotherapy Canada, 60(3), 215-223.   ? Feipel, V., Salvia, P., Klein, H., & Rooze, M. (2006). Head repositioning accuracy in patients with whiplash-associated disorders. Spine, 31(2) (pp E51-E58), Date of Publication: Jan 2006.   ? Heikkila, H., & Astrom, P. G. (1996). Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scandinavian Journal Rehabilitation Medicine, 28(3), 133-138.    References ? Hurwitz, E. L., Carragee, E. J., van der Velde, G., Carroll, L. J., Nordin, M., Guzman, J., et al. (2008). Treatment of neck pain: Noninvasive interventions: Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine, 33(4 Suppl), S123-52.   ? 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 RCT. Pain, 129(1-2), 28-34.   ? Kay, T. M., Gross, A., Goldsmith, C. H., Hoving, J. L., & Bronfort, G. (2009). Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews, 1   ? Loudon, J. K., Santos, M. J., Franks, L., & Liu, W. (2008). The effectiveness of active exercise as an intervention for functional ankle instability: A systematic review. Sports Medicine, 38(7), 553-563.   ? Lundmark, H., & Persson, A. (2006). Physiotherapy and management in early whiplash-associated disorders (WAD) ? A review. Advances in Physiotherapy, 8(3), 98-105.   ? Miller, J., Gross, A., D'Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., et al. (2010). Manual therapy and exercise for neck pain: A systematic review. Manual Therapy, 15(4), 334-354.   ? Rosenfeld, M., Gunnarsson, R., & Borenstein, P. (2000). Early intervention in whiplash-associated disorders: A comparison of two treatment protocols. Spine, 25(14), 1782-1787.   ? Sarig-Bahat, H. (2003). Evidence for exercise therapy in mechanical neck disorders. Manual Therapy, 8(1), 10-20.   References ? Soderlund, A., Olerud, C., & Lindberg, P. (2000). Acute whiplash-associated disorders (WAD): The effects of early mobilization and prognostic factors in long-term symptomatology. Clinical Rehabilitation, 14(5), 457-467.   ? Spitzer, W. O. (1995). Scientific monograph of the quebec task force on whiplash-associated disorders: Redefining'whiplash'and its management. Spine, 20, 1-73.   ? Sterling, M., Jull, G., Vicenzino, B., & Kenardy, J. (2004). Characterization of acute whiplash-associated disorders. Spine, 29(2), 182.   ? Sterling, M., Jull, G., & Kenardy, J. (2006). Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain, 122(1-2), 102-108.   ? Sterling, M., & Kenardy, J. (2008). Physical and psychological aspects of whiplash: Important considerations for primary care assessment. Manual Therapy, 13(2), 93-102.   ? Treleaven, J., Jull, G., & Sterling, M. (2003). Dizziness and unsteadiness following whiplash injury: Characteristic features and relationship with cervical joint position error. Journal of Rehabilitation Medicine, 35(1), 36-43.   ? Verhagen, A. P., ScholtenPeeters, G. G. G. M., van Wijngaarden, S., de Bie, R., & BiermaZeinstra, S. (2010). Conservative treatments for whiplash. Cochrane Database of Systematic Reviews, 2    


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