Psychology (in combination with other rehabilitation)

Injury type: Acute/ Chronic

Category: Allied Health Options

Rating: Promising

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 is literature evidence which indicates that people with whiplash can get long-term, sustained benefits from psychological/psychosocial interventions when used in combination with other treatments such as physiotherapy. These findings are based on robust body of evidence which suggests that interventions such as CBT and the Progressive Goal Attainment Program (PGAP), when used in conjunction with physiotherapy or exercises, improve various aspects of injury related outcomes in people with acute/ chronic whiplash.

A series of secondary analyses of a randomised controlled trial (RCT)^1-4  suggests that a behavioural approach in addition to neck-specific exercise leads to a better improvement in self-reported work ability and health-related quality of life, as opposed to neck-specific exercise alone or physical activity prescription. However, this combined intervention does not seem to be better at improving headache, radiating pain and signs of neurological deficits in grades II-III of chronic whiplash, than neck-specific exercise alone.

A recent RCT⁵ compared the effectiveness between a stress inoculation training delivered in conjunction with exercise and stand-alone exercise intervention. This study showed that the combined approach is more effective than exercise alone for improving pain-related disability in people with acute whiplash. Another cluster RCT⁶ also found that the intervention which addresses both physical and psychological components of whiplash is more effective than standard physiotherapy for people with acute grade II whiplash, in terms of recovery, pain intensity, cervical range of motion, pressure pain threshold and quality of life.

Two systematic reviews reported slightly varied findings in relation to integrated psychological/ psychosocial approach with physiotherapy/ exercise. In one review⁷, a combination of cognitive therapy and neck-specific strengthening exercise was found more effective than prescribed physical activity but not neck-specific strengthening exercise alone in reducing pain and disability. In another review⁸, while conflicting evidence was reported for the use of CBT, a PGAP with concurrent physiotherapy was likely to benefit patients with chronic grades I-III whiplash.

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.