The role of fear of movement in subacute whiplash-associated disorders grades I and II

Abstract

Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders (WAD). This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear. People still symptomatic from WAD grade I-II injuries approximately 3months previously (n=191) completed questionnaires (eg, Neck Disability Index [NDI]) and were randomized to 1 of the treatments: (1) informational booklet (IB) describing WAD and the importance of resuming activities, (2) IB+didactic discussions (DD) with clinicians reinforcing the booklet, and (3) IB+imaginal and direct exposure desensitization (ET) to feared activities. DD and ET participants received three 2-hour treatment sessions. Absolute improvements in NDI were in predicted direction (ET=14.7, DD=11.9, IB=9.9). ETs reported significantly less posttreatment pain severity compared with the IB (Mean=1.5 vs 2.3, P<.001, d=0.6) and DD (M=1.5 vs 2.0, P=.039, d=0.6) groups. Reduction in fear was the most important predictor of improvement in NDI (β=0.30, P<.001), followed by reductions in pain (β=0.20, P=.003) and depression (β=0.18, P=.004). The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome. Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and/or educational interventions to improve function.

Trial registration: ClinicalTrials.gov NCT00021476.

Figure 1

CONSORT Diagram of the study.

Figure 2

Overall improvement in post-treatment outcomes relative to baseline. IB, Informational Booklet; DD, Didactic Discussion; ET, Exposure Therapy NDI, Neck Disability Index; PFActS-C, Pictorial Fear of Activity Scale – Cervical; MPI, Multidimensional Pain Inventory; CPSS, Chronic Pain Self-efficacy Scale; PCLC, Post-traumatic Stress Disorder Checklist; PASS, Pain Anxiety Symptom Scale; CES-D, Center for Epidemiological Studies Depression Scale. *Significantly different compared to IB group only, in post-hoc tests. †Significantly different compared to both IB and DD groups, in post-hoc tests.

Figure 3

Mediational analysis for the relationship between treatment and functional improvement, through changes in fear. DD = Didactic Discussions; ET = Exposure Therapy; PFActS-C = Fear; NDI = Neck Disability Index. *** = p < 0.001.