Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: the Managing Injuries of Neck Trial (MINT) Intervention
From: Physiotherapy. 2009 Mar;95(1):15-23. Epub 2009 Jan 23
Managing Injuries of Neck Trial is a multi-centre randomised controlled trial to estimate the clinical effectiveness of a stepped care approach to whiplash injuries on clinical outcomes over 12 months, the effectiveness in pre-specified sub-groups of patients (those with severe physical symptoms, prior neck problems, psychological or physical risk factors for poor outcome, and those seeking compensation), and the costs and cost-effectiveness of each strategy.
This paper describes the development and implementation of a physiotherapy intervention for a large multicentred randomised controlled trial of the early management of whiplash injuries in a National Health Service setting. Participants were eligible if they were classified as having whiplash associated disorder grades I to III and self-referred for treatment within 6 weeks of injury. The intervention development was informed through a variety of methods including the current evidence base, published guidelines, clinician opinion, a pilot study and expert opinion. The intervention was targeted at known, potentially modifiable risk factors for poor recovery, and utilised manual therapy, exercises and psychological strategies. The treatment was individually tailored, with a maximum of six treatments allowed within the trial protocol over an 8-week period. The intervention was delivered to 300 participants. The amount and types of treatments delivered are described.
A substantial proportion of patients with whiplash injuries develop chronic symptoms. However, the best treatment of acute injuries to prevent long-term problems is uncertain. A stepped care treatment pathway has been proposed, in which patients are given advice and education at their initial visit to the emergency department (ED), followed by review at three weeks and physiotherapy for those with persisting symptoms. Managing Injuries of Neck Trial is a two-stage randomised controlled trial to evaluate two components of such a pathway: 1. use of The Whiplash Book versus usual advice when patients first attend the emergency department; 2. referral to physiotherapy versus reinforcement of advice for patients with continuing symptoms at three weeks.
Definitions of whiplash and associated conditions vary between published studies. The Quebec Task Force (QTF) definitions are internationally recognised and are used in this study. Whiplash is the mechanism of injury (acceleration-deceleration injuries usually in the frontal plane), whiplash injuries are the soft tissue injuries that result and Whiplash Associated Disorder (WAD) describes the pattern of symptoms that arise. A further term, late whiplash syndrome, is used to describe the chronic complications of whiplash.
Managing Injuries of Neck Trial is a two-stage randomised controlled trial to evaluate two components of such a pathway: 1. use of The Whiplash Book versus usual advice when patients first attend the emergency department; 2. referral to physiotherapy versus reinforcement of advice for patients with continuing symptoms at three weeks.
A stepped care clinical pathway as proposed by the QTF is the model evaluated in this trial. The advice and education component to be evaluated is The Whiplash Book. This has been developed largely based on the results of a systematic review, which suggested that psychological risk factors are the strongest predictors of poor outcome in whiplash patients, and argued that advice to resume normal activity, using a cognitive-behavioural approach, should be the treatment of choice for early management. However, other systematic reviews have suggested that physical and psychological factors may carry equivalent amounts of risk for poor outcome. Furthermore, most of the literature cited to support the early activity and key health promotion messages was from the field of low back pain and other chronic conditions. It is questionable whether these results are transferable to acute whiplash injuries, as the conditions differ markedly in their causes and psychological consequences. For example, phobic travel anxiety and other psychological manifestations of shock are common after whiplash, but rarely occur with low back pain.
The second component of the stepped care approach evaluated in Managing Injuries of Neck Trial is physiotherapy for patients whose symptoms have not resolved by three weeks. Physiotherapy treatments that are commonly used for whiplash patients include hot and cold therapy, electrotherapies, mobilisation, manipulation, exercises of many different kinds, and traction. There is good quality trial evidence to support the effectiveness of mobilisation and exercise in the management of chronic neck pain, but it is uncertain whether these treatments are effective for whiplash patients. The Cochrane review of conservative treatments for whiplash concluded that there was some evidence that active treatments are superior to passive, though the existing trials were not of high quality. Another review concluded that there was moderate quality evidence that exercises and mobilisations commonly used by physiotherapists were effective, but this was based on just three small trials, which reported short-term outcomes only, did not perform intention to treat analyses, and did not have blinding of outcome assessment. For evaluation in Managing Injuries of Neck Trial is a package of physiotherapy treatments that, according to current evidence, are those most likely to be effective in prevention of late whiplash syndrome and to be acceptable to practitioners.
Three treatments are included in the physiotherapy package:
(1) Mobilisation (gentle manipulation) of the cervical and upper thoracic spine according to Maitland.
(2) Exercises for the cervical spine, thoracic spine and shoulder to improve range of movement and muscle control.
(3) A cognitive behavioural approach to treatment delivery, which has been effective in physiotherapy for other painful conditions.
