Dry needling and exercise for chronic whiplash – a randomized controlled trial.
From: BMC Musculoskelet Disord. 2009 Dec 18;10(1):160.
Persistent chronic pain following whiplash injury as a result of a motor vehicle crash is a common and costly problem. The maintenance of activity and exercises is recommended for the management of whiplash. However, trials of treatment approaches including exercise and activity for chronic whiplash have demonstrated only modest effects on pain and disability levels. One reason for these modest effects may be due to the heterogeneous nature of the whiplash condition. Many people with chronic whiplash have a complex clinical presentation with marked sensory disturbance (widespread hyperalgesia, sympathetic nervous system dysfunction) indicative of central nervous system hyperexcitability. The presence of these factors is associated with higher levels of pain and disability and poor functional recovery. The authors data also indicate that patients with these features show a poor response to an exercise based intervention approach.
Modalities such as dry-needling and acupuncture are commonly used in the treatment of musculoskeletal pain conditions. With respect to neck pain of all types and not specifically whiplash, a recent systematic review reported moderate evidence for pain relieving effects of these approaches. Furthermore, these modalities can have a modulatory effect on hyperalgesia and they are effective in alleviating symptoms of fibromyalgia, a condition that also features characteristics of central hyperexcitability. Together these findings suggest that needling techniques may be effective in the management of chronic whiplash pain, but the use of such interventions in this condition has never been investigated.
A recent Cochrane review concluded that dry-needling, added to other conventional therapies such as exercise, is more effective at relieving pain than conventional therapies alone in non-specific low back pain. This combined approach to management has never been investigated in whiplash. Therefore the primary aim of this project is to investigate the effectiveness of dry-needling, advice and exercise compared with sham dry-needling, advice and exercise in chronic whiplash. Effectiveness will be measured by reductions in pain and disability levels and improvements in patients’ impressions of overall recovery and quality of life. The secondary aim is to conduct an economic evaluation of the dry-needling, advice and exercises.
All participants will be provided with the patient educational booklet Whiplash injury recovery: A self management guide published by the Motor Accident Insurance Commission, which provides information about whiplash, advice on symptom management and illustrates a simple exercise program. Participants will be randomised to one of two groups. Participants in Group 1 will receive 6 treatments of combined dry-needling and exercise delivered in the first 3 weeks of the 6 week program, and 4 treatments of exercise only in the last 3 weeks of the program.
Participants in Group 2 will receive an identical protocol, except that a sham dry-needling technique is used instead of dry-needling. Sham dry-needling uses needles which cause a pricking sensation when pushed against the skin. The needle disappears into the handle with increased pressure. This mechanism invokes a similar sensation to that produced by dry-needling, which includes the non-specific effects of clinician – therapist contact and explanation, as well as the perception that the needle is entering the skin, although sham dry-needling is proposed to have less physiological effect than true needling. Needling sites will be dependent on findings by the physiotherapist following assessment for the presence of hyperalgesia on palpation. Only posterior muscles of the cervical spine and upper thoracic spine will be treated while the participant is lying prone, to ensure the participant remains blinded to the needling group allocation. Examples of posterior muscles which may be treated are the trapezius, levator scapulae, splenius capitus, semispinalis and spinalis capitis muscles.
The 6-week exercise program will be carried out under supervision from the physiotherapist and will comprise specific exercises to improve the movement and control of the neck and shoulder girdles. The exercises will be tailored by the physiotherapist for each individual participant, are of a low load nature and are designed to be pain free. At the same time, the physiotherapist will guide the subject’s return to normal activities. This program is similar to those utilised by physiotherapists in clinical practice and has been used in previous studies.
Primary outcome measures
1. Neck-specific measure of disability (Neck Disability Index)
2. Patient’s global impression of recovery (-5 to +5 scale)
Secondary outcome measures
3. Average pain intensity over last week (Visual Analogue Scale)
4. Average pain intensity over last 24 hours (Visual Analogue Scale)
5. Patient-generated measure of disability (Patient-Specific Functional Scale)
6. Whiplash-specific measure of disability (Whiplash Disability Questionnaire)
7. Generic measure of health status (SF-36)
8. Measures of physical impairment (Cervical range of movement, pressure pain threshold, cold pain threshold)
9. Impact of events scale (IES)
10. Pain Catastrophising Scale (PCS)
11. Posttraumatic stress Diagnostic Scale (PDS)
12. Self report Leeds Assessment of Neuropathic Symptoms and Sign (S-LANSS Pain Score)
Although many people experience rapid recovery from pain and disability associated with whiplash within the first three months, a significant proportion can have ongoing mild to moderate pain and disability. It has been shown that the presence of widespread sensory hypersensitivity indicative of augmented pain processing mechanisms is associated with higher levels of pain, disability and poor functional recovery following whiplash injury. Chronic patients with these features have been shown to have a poor response to an exercise based intervention approach. In order to enhance the treatment outcomes of an exercise intervention, an additional modality or technique could be used in conjunction with an exercise program to address the sensory hypersensitivity of whiplash. Modalities such as dry needling and acupuncture are commonly used in the treatment of musculoskeletal pain conditions, although the benefit of dry needling for the treatment of whiplash is not yet known. Therefore, this trial aims to investigate whether the addition of dry needling to an exercise program will reduce pain and disability of chronic whiplash.
The exercise programme received by all participants in the trial includes specific exercises to re-educate cervical and scapular muscle control endurance and strength and are of low-load in nature. These exercises are tailored to the ability of the participants by the trial physiotherapists. This type of exercise programme has previously shown modest effects in the treatment of chronic whiplash by reducing pain and disability and was therefore the program of choice for this trial.
A sham dry needling intervention will be used as a in the comparison group to assess the effects of dry-needling on whiplash. Sham dry needling invokes a similar sensation to that produced by true dry-needling, without the needle entering the skin. This technique is proposed to have a lesser physiological effect than true needling. Application of the sham and true dry needles are to the posterior cervical and thoracic spine whilst the participant is prone, which will allow participant blinding to their group allocation. A blinded independent trial assessor will conduct participant assessments. The methodology of this double-blind randomised controlled trial meets the CONSORT statement and guidelines.
An economic evaluation of the dry-needling, advice and graded exercise approach will also be conducted as a secondary aim in this trial. As the economic cost of whiplash injury is extensive, developing effective treatment programs which minimize pain, disability and resultant economic cost is desirable.
It is hypothesised that the dry needling approach will decrease the pain and disability of chronic whiplash by reducing the sensory hypersensitivity and facilitate the effects of the exercise program. The study outcomes will facilitate the development of effective treatment plans for chronic pain and disability following a whiplash injury and have the potential to reduce the economic burden of this condition.
List of Exercises
1. Flexors of the craniocervical spine: Re-education of cranio-cervical flexion movement. Training holding capacity of the neck flexors. Retraining eccentric control of the cranio-cervical flexors in upright postures.
2. Extensors of the craniocervical spine: Re-education of cranio-cervical extension movement . Training holding capacity of the neck extensors.
3. Re-education of neutral posture: Re-education of neutral spine in sitting, including lumbopelvic, thoracic and cervical spine. Progression to other functional postures (patient specific)
4. Retraining of the scapular muscles: Retraining scapular orientation in neutral posture. Training endurance capacity of the scapular stabilizers. Retraining dynamic scapular control with arm movement and load.
5. Co-contraction of the neck flexors and extensors: Facilitated with rotation, using self-resisted isometric rotation in either supine, or in correct upright sitting posture.
6. Strength training of the flexor synergy: Head lift in supine, preceded with cranio-cervical flexion followed by cervical flexion to just lift the head from the supporting surface. Graded reduction in pillow height to flat surface.
