Fear-avoidance interventions

In clinical practice, the chronic whiplash syndrome is often considered a specific form of a chronic pain syndrome, not essentially different from chronic low back pain or functional syndromes. One of the most influential models in the context of chronic low back pain is the so-called fear-avoidance (FA) model. The FA model promises to aid understanding about how acute whiplash may develop into chronic complaints.^{4, 5} In Chapter 8, the FA model was reformulated to better understand chronic WAD. In this causal beliefs–anxiety (CBA) model, the role of culturally embedded (dysfunctional) causal attributions of whiplash symptoms is more prominent than in the FA model (see Fig 8.1 in Chapter 8).

The review of psychological determinants in Chapter 8 suggests that, in comparison with chronic low back pain, attributional bias and pain catastrophising may be more influential than kinesiophobia in the development and maintenance of chronic WAD. This is an important conclusion with clinical implications. The CBA model implies that realistic attributions of neck pain will result in uncomplicated recovery. The results of a recent study support this assumption: early expectations for recovery of WAD (a few weeks after the accident) were an important prognostic factor for recovery; those who expected to get better soon recovered over three times as quickly as those who expected that they would never get better.⁶

Most importantly for the present context, the CBA model provides a helpful starting point for specific cognitive and behavioural interventions, known as cognitive behavioural therapy (CBT). Importantly, CBT does not refer to a unitary treatment but rather includes a wide range of different interventions. Cognitive restructuring is of primary importance in order to change attributional bias and pain catastrophising.

Pain catastrophising refers to an exaggerated negative orientation towards actual or anticipated pain. The habitual tendency to make catastrophic interpretations of pain is associated with a heightened pain experience and heightened disability, independent of the level of actual physical impairment.⁷ Causal attributions or illness beliefs can be defined as the patient’s ideas about the origin or cause of the symptoms or illness experienced. The causal beliefs of the patient are very relevant in relation to the persistence of complaints when an organic cause has not been verified, as in chronic WAD. These illness perceptions or cognitive representations directly influence behaviour parameters and the emotional response.⁸

Dysfunctional causal beliefs in WAD can be defined as the attribution of the cause of acute neck complaints to severe, neural or irreparable causes. At the chronic stage of WAD, somatic or organic beliefs, in general, can be considered dysfunctional. The tendency to attribute neck complaints to irreparable or severe causes may elicit catastrophic interpretations of potentially benign muscular symptoms.

The first step in the CBT intervention, cognitive restructuring, involves identifying the dysfunctional causal attributions by assessing in which situations these attributions occur, assessing the concrete contents of the attribution (e.g. ‘This pain means something must be broken in my neck’) and establishing the emotions that arise from the attribution. Registration of these situations, cognitions and emotions in daily life is often the first homework assignment in CBT for the patient with chronic WAD. In the second step, the dysfunctional beliefs are evaluated and defined by asking questions like: ‘What evidence is there for this attribution?’ and ‘Does this attribution help you to feel better?’. The third step is to formulate a more realistic and/or helpful attribution and evaluate the effect of this reformulation on the emotional state.

This cognitive approach is often followed by so-called behavioural experiments, aimed at testing the dysfunctional attribution. Catastrophic predictions of what would happen if the patient should perform some avoided movement or behaviour can be refuted in this way. This exposure in vivo to the threatening behaviour is often more convincing than cognitive restructuring alone.

Patients with chronic WAD often show a wide range of avoidance behaviour, especially concerning movements of the head and neck (as a result of kinesiophobia, see Fig 8.1), but also concerning all kinds of physical and social activities. As with other functional syndromes, the pain and other complaints have become a central focus in life and have consequences for many aspects of functioning. CBT for functional syndromes not only focuses on causal attributions for symptoms, but also on these consequences for normal functioning.⁹ These consequences may vary from affective and cognitive consequences (e.g. depression, problems with attention and concentration), behavioural consequences (e.g. avoidance behaviour), physical consequences (e.g. increased muscle tension, loss of physical condition) to social and professional consequences (e.g. social isolation, loss of job).

The primary goal of CBT for functional syndromes mostly is not to reduce pain or other symptoms, but to reduce or redress these invalidating consequences. That is why interventions like graded activity and physical exercises fit well in a cognitive behavioural approach for patients with chronic WAD.

Formulating concrete treatment goals in dialogue with the patient is an essential element before starting CBT. After thoroughly drawing up an inventory of the specific consequences of chronic WAD for the patient, the therapist and patient can decide which consequences will be tackled and what will be the concrete goals (e.g. full return to work or resume earlier sporting activities).

Psycho-education or patient education is an often-applied intervention in patients with acute WAD, although the effectiveness of this intervention is unclear.¹⁰ Psycho-education is an important intervention for patients with chronic WAD. It can be the first step in altering dysfunctional attributions and it provides a rationale for CBT. An individualised version of the CBA model can be explained and discussed, resulting in a better understanding of the course and maintenance of chronic WAD for the patient.

Within the context of CBT, recently developed approaches, such as acceptance and commitment therapy and mindfulness-based interventions, have been successfully applied to chronic pain. The relative efficacy of these types of interventions in the treatment of chronic WAD have recently been evaluated,¹¹ and will be discussed in the next section.

A case description is given on page 137 to illustrate the CBA model.

Post-traumatic stress disorder interventions

Another promising model that seeks to explain the psychological effects of traffic accidents is the PTSD model. The essential feature of PTSD is the development of characteristic symptoms following exposure

Research has provided evidence to indicate that post-traumatic stress symptoms are related to WAD. Hyperarousal symptoms, especially, have been shown to be involved in patients with chronic WAD.¹² However, there is evidence that the other symptom clusters may be involved as well.¹³ The co-occurrence of anxiety disorders (especially PTSD) and chronic pain syndromes (especially WAD) has recently been the subject of some debate. Some theorists propose that there might be a reciprocal relationship, with PTSD and WAD influencing one another in a mutual maintaining way.¹⁴ This mutual maintenance model holds that physiological, affective and behavioural components of PTSD maintain or exacerbate symptoms of pain and, similarly, that cognitive, affective and behavioural components of chronic pain maintain or exacerbate symptoms of PTSD. A recent empirical examination of the model in a longitudinal study of injured accident victims yielded support for a mutual maintenance of pain intensity and PTSD symptoms in the first half year after the accident.¹⁵ Across the second half year, PTSD symptoms impacted significantly on pain but not vice versa. So, over time no reciprocal relationship was found. The mutual maintenance model has been extended, suggesting that some maintenance factors denote a shared vulnerability for developing both conditions.¹⁶ This shared vulnerability model stresses three predisposing factors in the development of both disorders: psychological vulnerability (e.g. high anxiety sensitivity), confrontation with traumatic life events (e.g. a traffic accident), and a lowered physiological threshold for alarm reactions (e.g. sympathetic dysregulation, hyperalgesia). So, co-occurring PTSD and chronic WAD are most likely to develop in cases where vulnerable people are exposed to a car accident that is both traumatic and painful, wherein reminders of the trauma and sensations of pain can serve as triggers for further alarm reactions.

The potential role of the stress response system in understanding the aforementioned alarm reactions is stressed in the theoretical model of McLean et al.,¹⁷ who reformulated the FA model, incorporating the hypothesised role of the stress response system in the development of aberrant pain and/or emotional processing after an MVC. Recent research on the relationship between sensory and sympathetic nervous system changes and post-traumatic stress reaction following WAD showed that this relationship was mediated by pain and disability levels.¹⁸ Therefore, interpretation of this relation is difficult and warrants further investigation.

There are several clinical implications of the co-occurrence of chronic WAD and PTSD. Primarily, PTSD and subclinical post-traumatic stress symptoms warrant clinical attention. Patients with chronic WAD do not always report post-traumatic stress symptoms spontaneously, so active exploration of these symptoms should occur.

Several evidence-based interventions are available for the treatment of PTSD. Trauma-focused CBT and eye movement desensitisation and reprocessing (EMDR) are highly effective treatments for PTSD.^{19, 20} Imaginal exposure is the most applied trauma-focused CBT intervention for PTSD. The patient is systematically and repeatedly confronted with the anxiety-provoking memories of the traumatic events by telling the therapist in a structured way about the traumatic events. At first, exposure to these memories can evoke anxiety and other negative emotions, but after repeated confrontation the emotional reactions decrease. Repeated exposure to the trauma memory can also be accomplished by letting the patient write a narrative of the traumatic events. So, structured writing about the trauma is another trauma-focused CBT intervention that may prove useful. In general, these interventions have a positive effect on all three clusters of symptoms of PTSD.^{21, 22} In some cases, however, avoidance behaviour, especially avoidance of driving a car, can persist.²³ Then, exposure in vivo is a necessary additional intervention to free the patient of this fear to participate in driving.

EMDR is another highly effective intervention for PTSD, specifically when exposure is included in the treatment protocol.²⁴ EMDR utilises dual attention tasks to help the patient process the traumatic event and involves focusing on negative trauma-related memories, emotions and thoughts while engaging in a task involving some form of bilateral stimulation, such as eye movements, hand tapping or tunes, until distress has reduced and belief in more positive trauma-related thoughts has increased.²⁰

A CBT intervention that is less frequently applied to PTSD and/or chronic pain is interoceptive exposure (i.e. exposure to anxiety-provoking bodily sensations). This intervention is highly effective for panic disorder, as it helps to modify the catastrophic idea that particular bodily sensations are predictive of a heart attack. Recently, interoceptive exposure has been added to trauma-focused interventions to reduce both PTSD symptoms and fear of pain.²⁵ In this study, interoceptive exposure preceded trauma-focused interventions. The rationale was that interoceptive exposure would decrease anxiety sensitivity (one of the predisposing factors in the shared vulnerability model), a determinant of both PTSD and chronic pain. Interoceptive exposure is the first intervention aimed at reducing both PTSD and chronic pain by focusing on a shared predisposing factor. Exposure in vivo has been applied to both PTSD and chronic WAD too, but for the reduction of different kinds of avoidance behaviour. Avoidance behaviour in PTSD mostly concerns driving a car or avoiding (other) situations that evoke traumatic memories. Avoidance behaviour in chronic WAD mostly concerns situations that evoke neck pain.

A case description is given below to illustrate the PTSD model.

Related posts:

Epidemiology of whiplash associated disorders Potential role of stress systems in the pathogenesis of whiplash associated disorders Future directions Case descriptions Neuromuscular dysfunction in whiplash associated disorders The evidence for pathoanatomical lesions

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