Improving Psychologically Oriented Treatments for WAD
Steven James Linton
For reasons not fully understood, many patients who sustain a WAD (whiplash-associated disorder) recover quickly, while others develop long-term problems. Psychological factors offer one enticing explanation for why WAD may become persistent [25], and psychologically oriented treatments have therefore been evaluated in some intervention studies. Indeed, because WAD all too often develops into a debilitating problem, it presents a unique challenge for the application of psychologically oriented pain interventions. Indeed, psychological treatments have been proposed as a way of implementing a biopsychosocial approach to a difficult problem [19] (see Turk and Robinson Chapter 11 in this volume for an overview of the biopsychosocial model in WAD). Yet the application of psychological treatments is not uniform, and they are offered at different points in time, in diverse formats, by a range of professionals, in a wide variety of settings. Consequently, there is a need to sort out what psychological treatment components might be applicable, how well they work, and for whom. Since WAD continues to be a problem for the individual, their family, the workplace, and society, there is also a need to examine how psychological approaches might be improved.
My point of departure, then, is how psychology might contribute to meeting the challenge of effectively treating WAD. To this end, the aim of my chapter is to review, with an eye on improvement, the role
of psychological treatments for WAD. I will first provide important background for understanding what psychological interventions may be applicable and when they might best be applied. Subsequently, I will examine some of the treatments themselves and explore the results obtained to date. This is central since the field is facing major challenges in providing effective interventions that will prevent chronic WAD, rehabilitate those with persistent WAD, while at the same time being cost-effective and applicable to several clinical settings. Finally, given this great challenge, I will emphasize some ways in which the application of psychological interventions might be improved.
of psychological treatments for WAD. I will first provide important background for understanding what psychological interventions may be applicable and when they might best be applied. Subsequently, I will examine some of the treatments themselves and explore the results obtained to date. This is central since the field is facing major challenges in providing effective interventions that will prevent chronic WAD, rehabilitate those with persistent WAD, while at the same time being cost-effective and applicable to several clinical settings. Finally, given this great challenge, I will emphasize some ways in which the application of psychological interventions might be improved.
SALIENT PSYCHOLOGICAL FEATURESPsychological interventions target certain underlying psychological mechanisms that are believed to be of the greatest importance. While many individual variables have been implicated, let us focus on a few of the most fundamental factors. To understand how psychological factors impact on people suffering WAD, it is crucial to underscore how the problem develops or remits over time. As with other forms of pain, WAD is triggered by an injury, and there are several ensuing trajectories for recovery (full or partial) or development toward persistence (recurrent problem, stepped problem) [8, 32]. A particular feature of this process is that the repeated episodes of pain provide plenty of opportunity for psychological factors to impact upon the course of development [26, 53]. I suspect that this occurs in stages where certain factors like fear, catastrophizing (the tendency to misinterpret and exaggerate situations as dangerous), and symptoms of PTSD are prevalent early on. As time goes on without recovery, other processes are added such as worry, frustration, and difficulties in problem solving caused by persistent pain. In the chronic stage, individuals with WAD are plagued by a host of psychological factors that maintain the problem (e.g., depression, inactivity, inflexibility, shame, guilt [28]).
Table 12-1 provides an overview of some basic psychological factors that may influence the course of WAD and suggested time points for their peak relevance. The table also shows some suggested treatments
targeting the psychological factor noted and these listed will be examined more closely below. As Table 12-1 shows, several psychological factors on the behavioral, cognitive, and emotional planes come into play. Typically, WAD is associated with a traumatic injury (e.g., an automobile accident), and early research demonstrated a link between the injury and problems associated with Posttraumatic Stress Disorder (PTSD) [7]. The injury also triggers pain and soft-tissue symptoms like swelling and stiffness. The Fear and Avoidance model is therefore particularly applicable during the early stage of the problem [58, 59]. Briefly, this model suggests that the pain triggers catastrophic thoughts and fear that focus attention on the injury and result in the avoidance of movements believed to be dangerous for exacerbating the pain and causing further injury. When the problem recurs or persists, this is thought to trigger more catastrophic worry, and a host of negative emotions including anger and frustration [14, 52]. The emotional distress and cognitive activity is believed to contribute to the problem and makes solutions more difficult. Anger, for example, is a prevalent reaction known to be related to chronic pain [52]. Further, some patients may feel victimized since the accident was not their fault and they may have experienced problems in receiving adequate treatment [48]. Increasingly, they may face important goal conflicts (e.g., on the one hand
wanting to participate in work, family, and social activities, while at the same time not wanting to exacerbate their pain or the injury) [56]. This process may result in even more distress including shame and guilt, inflexible thinking patterns that make creative problem solving difficult and generally leave the individual vulnerable to a variety of additional problems such as unemployment, relational problems, and depression [28]. This range of factors opens the door to a range of treatment interventions that might be initiated from the point of injury forward.
targeting the psychological factor noted and these listed will be examined more closely below. As Table 12-1 shows, several psychological factors on the behavioral, cognitive, and emotional planes come into play. Typically, WAD is associated with a traumatic injury (e.g., an automobile accident), and early research demonstrated a link between the injury and problems associated with Posttraumatic Stress Disorder (PTSD) [7]. The injury also triggers pain and soft-tissue symptoms like swelling and stiffness. The Fear and Avoidance model is therefore particularly applicable during the early stage of the problem [58, 59]. Briefly, this model suggests that the pain triggers catastrophic thoughts and fear that focus attention on the injury and result in the avoidance of movements believed to be dangerous for exacerbating the pain and causing further injury. When the problem recurs or persists, this is thought to trigger more catastrophic worry, and a host of negative emotions including anger and frustration [14, 52]. The emotional distress and cognitive activity is believed to contribute to the problem and makes solutions more difficult. Anger, for example, is a prevalent reaction known to be related to chronic pain [52]. Further, some patients may feel victimized since the accident was not their fault and they may have experienced problems in receiving adequate treatment [48]. Increasingly, they may face important goal conflicts (e.g., on the one hand
wanting to participate in work, family, and social activities, while at the same time not wanting to exacerbate their pain or the injury) [56]. This process may result in even more distress including shame and guilt, inflexible thinking patterns that make creative problem solving difficult and generally leave the individual vulnerable to a variety of additional problems such as unemployment, relational problems, and depression [28]. This range of factors opens the door to a range of treatment interventions that might be initiated from the point of injury forward.
TABLE 12-1 Examples of Psychological Factors that Affect WAD According to the Time Point for Their Peak Relevance | |||||||||||||||
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Psychological Interventions and Their Effectiveness
Psychological interventions are designed to target various underlying mechanisms, and they are often provided in a diversity of settings, from emergency rooms to rehabilitation clinics. The amount of intervention provided also varies grossly, with some programs offering only an hour or 2 as part of a broader treatment, while others provide considerable amounts. Typically, psychological interventions are coordinated with other interventions, and they may be provided by psychologists or sometimes by other members of a team. Thus, psychological treatments are quite heterogeneous, and this variation may account for differences in outcome in addition to the actual choice of the psychological treatment.
PTSD-Focused Treatments
Many people sustain a WAD in a motor vehicle collision that may also trigger PTSD symptoms [47]. It is estimated that at least 25% of those with WAD associated with a car crash also display significant PTSD symptoms [47]. This anxiety disorder comprises three groups of symptoms: avoidance of stimuli associated with the accident, arousal (e.g., hypervigilance and the re-experiencing of the trauma). In addition to the disability itself, pain catastrophizing and perceived injustice have been found to be salient factors propelling the problem Sullivan et al. [50]. Fortunately, cognitive-behavioral therapy (CBT) has shown clear benefit for PTSD-associated problems with large effect sizes [3, 6]. One
central theme in these treatments is to focus on the trauma. In particular, exposure training (similar to that used for phobias) is employed where patients are gradually exposed until habituation occurs for the stimuli that trigger the symptoms. For those patients with a WAD diagnosis who also have PTSD, psychological treatment may offer clear help.
central theme in these treatments is to focus on the trauma. In particular, exposure training (similar to that used for phobias) is employed where patients are gradually exposed until habituation occurs for the stimuli that trigger the symptoms. For those patients with a WAD diagnosis who also have PTSD, psychological treatment may offer clear help.
As an example, a randomized controlled trial compared a trauma-focused CBT intervention with a waiting-list control for those with chronic (Mean = 28 months) WAD (grades II and III) and comorbid PTSD [11]. The treatment was based on guidelines for PTSD interventions and consisted of 10, 1-hour individual sessions with a psychologist. The results, despite a relatively small number of participants (13 per group), showed large and significant differences. In terms of the PTSD, those in the CBT group experienced a significant reduction of symptoms, and 8 of 13 no longer fulfilled the criteria for the disorder. Moreover, the CBT group, relative to the control, also had large improvements in a variety of other variables including function. Clinically significant reductions in both the PTSD and the WAD symptoms underscore the potential of this type of treatment. Targeting of treatment to those with clear psychological problems may be appropriate since the content, duration, and delivery of psychological treatment to all individuals with WAD have limitations. For example, the inclusion of psychological treatment as an add-on to physical therapy has not shown effectiveness [19, 45], and some individuals do not accept such treatments [16, 24]. Thus, targeting PTSD symptoms with an evidence-based CBT intervention has promise for those suffering comorbid problems.
Fear Avoidance Targeted
A second target for psychological treatment is based on the fear and avoidance conceptualization described above [41, 58]. In order to treat the avoidance behavior and relieve catastrophic worry and fear, exposure in vivo is recommended since it has a good evidence base for chronic pain in general [2, 36, 60]. Indeed, patients with a WAD
diagnosis often avoid movements they believe will exacerbate their pain or result in injury. Treatment is based on identifying movements that provoke this fear and therefore maintain avoidance, and then systematically exposing the patient to these movements to achieve extinction of the feared response.
diagnosis often avoid movements they believe will exacerbate their pain or result in injury. Treatment is based on identifying movements that provoke this fear and therefore maintain avoidance, and then systematically exposing the patient to these movements to achieve extinction of the feared response.
Several investigations have shown that exposure may be helpful for those fulfilling the criteria for fear and avoidance. First, a controlled trial with 8 patients demonstrated that exposure was viable and resulted in a larger decrease in fear, pain intensity, and disability than that in a comparison group receiving activity training [10]. Second, a randomized controlled trial featuring exposure and acceptance demonstrated that a 10-session protocol resulted in significantly larger improvements in disability, satisfaction, fear, and depression relative to a waiting-list control [62]. Although participants had symptoms for an average of nearly 7 years, this relatively brief treatment had a substantial effect.
A well-designed and executed trial featured the role of fear in the treatment of WAD [41]. This study of nearly 200 people with relatively minor WAD symptoms (grades I and II [46]) for 3 months compared three types of intervention: an information booklet, the booklet plus didactic discussions, and exposure therapy. Treatment was brief, just 3, 2-hour sessions. However, based on pre- to posttreatment evaluations, the exposure treatment resulted in superior outcomes (e.g., for pain intensity and neck function). Indeed, on the Neck Disability Index [57], those receiving exposure improved nearly 15 points, on average, which is far better than the minimally clinically important level that has been found to range between 3.5 and 9.5 points [41]. Importantly, this study also showed that a reduction in fear was the most important predictor of improvements in function. Thus, this study provides strong support for the idea that fear and avoidance is an important factor and that successfully treating it leads to clinically notable improvements.
Related posts:
Mechanisms of Joint Pain
Quantifying Dysfunction in Whiplash Injury: Old Questions, New Methods
What is Needed to Establish Valid Predictors of WAD Recovery?
How Do We Prevent the Transition from Acute to Chronic Pain After Whiplash Injury?
Precollision Risk Factors, Illness-Related Cognition, and Recovery After Acute Whiplash Trauma
Manual and Exercise Therapies in Whiplash-Associated Disorders
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