Features Practice Technique
Physiotherapy Treatment

Physiotherapy is a professional health care discipline directed primarily towards the prevention or alleviation of movement dysfunction in people.

A physiotherapist is a university graduate of an accredited physiotherapy program qualified to:

• establish a physical diagnosis and determine a client’s movement potential;
• plan and implement physiotherapy treatment programs, using specialized knowledge and skills in exercise prescription and hands-on techniques for the prevention and treatment of movement dysfunction;
• undertake related professional activities such as research, teaching, administration and consultation.

Physiotherapists Use:

• skilled “hands on” treatments such as soft tissue mobilization, acupressure and manipulation;
• lasers, ultrasound, magnetic fields, electrical currents, acupuncture, and heat and ice to relieve
• pain and assist recovery;
• individually prescribed exercise programs, relaxation techniques, sophisticated diagnostic and treatment equipment, hydrotherapy and biofeedback;
• suitable assistive devices such as walking aids, splints, orthotics, prosthetics and other therapeutic appliances and train patients in their correct use.

Short-Term Goals for this client; including method of treatment utilized to reach those goals
Whiplash is commonly referred to as Whiplash Associated Disorder (WAD) and it is graded according to the following:
0 – No complaint about the neck. No physical sign(s)
I – Neck complaint of stiffness, pain, or  tenderness. No physical sign(s)
II – Neck complaint AND Musculoskeletal sign(s)*
III – Neck complaint AND Neurological sign(s)**
IV – Neck complaint AND Fracture or dislocation

* Musculoskeletal signs include decreased range of motion and point tenderness.

** Neurologic signs include decreased or absent deep tendon reflexes, weakness and sensory deficits.

Symptoms and disorders that can manifest in all grades include deafness, dizziness, tinitus, headache, memory loss, dysphagia, and temporomandibular joint pain. Based upon the case history, Mrs. Jones would be diagnosed with Grade II WAD since she is only one week post-injury and is in the sub-acute phase of healing. The goals of the rehabilitation process include the following seven areas:

1.  Support the tissue healing process
Reaction Phase (< 4 days):
Minimize the normal inflammatory phase (vasodilation, exudation of tissue fluids, extravasation of blood,
secondary reactive edema, stimulation of pain fibres, chemotaxis of cells, activation of the immune response,
initiation of cell production):

• ice
• elevation
• application of cooling modalities
• appropriate splinting
• protected activity (range of motion within the pain free range, without resistance)

Regeneration Phase (variable – from 0-6 weeks):
Optimize the normal regenenerative phase (elimination
of debris, revascularization, fibroblast proliferation):

• minimize swelling
• protect neurovascularization
• limit duration of inflammatory response
• stimulate protein production

Remodeling Phase (1-3+ months):
Influence the remodeling phase (contraction of scar
tissue, maturation of collagen, increase in tensile strength) through influence on the strength and quantity of
connective tissue:

• minimize immobilization
• balance increasing functional stresses with increasing tissue strength
• re-establish range
• enhance proprioception

2.  Restore Range of Motion and Joint Mobility
Methods may include, but are not limited to: 

• Teach range of motion exercises – beginning with active assisted and active exercise, with specific focus on restoring right rotation and lateral flexion
• Use manual therapy techniques such as joint glides to mobilize areas of stiffness
• Use soft tissue techniques to reduce soft tissue resistance, decrease pain and restore mobility

3.  Decrease muscle spasm
Once the source of the spasm has been identified,
the underlying cause can be treated. Methods may
include, but are not limited to:

• soft tissue and manual therapy techniques to restore pain-free ROM
• electrotherapy modalities
• biofeedback

4.  Manage pain and reduce reliance on medication
Methods may include, but are not limited to:

• provide reassurance and education regarding the benign nature of whiplash and the rehabilitation and recovery process
• teach relaxation strategies
• electrotherapy modalities such as TNS, Interferential current
• acupuncture

5.  Restore ability to manage ADLs
Methods may include, but are not limited to:

• educate the patient regarding hurt versus harm
• teach proper body mechanics and neck-sparing techniques for activities which require push, pull, lift or awkward positioning (i.e. using the larger muscle groups, maintaining neutral spine posture)
• teach pacing and prioritizing (i.e. use microbreaks, break tasks into smaller components, etc.)
• provide functional, dynamic strengthening exercises
• engage the support of family members where feasible

6.  Restore ability to manage the demands of her job
Methods may include, but are not limited to:

• Address the ergonomics of her computer workstation (ensure proper seating with adjustability and adequate spinal support, appropriate height of monitor, distance to keyboard and mouse, etc.)
• Provide education regarding workstyle (microbreaks, proper positioning of arms, maintenance of neutral neck position, etc.)
• Assess job demands and recommend suitable activities
• Provide exercises to promote good postural alignment, trunk stability and postural endurance
• If feasible, design and implement a graduated return to work plan.

7.  Prevent Chronicity / Re-aggravation
Methods may include, but are not limited to:

• Exploration of the patient’s coping strategies
• Support and reassurance
• Encourage active participation in the recovery and decision-making process
• Identification of community resources
• Communication with other members of the treatment team (e.g. Physician, Specialist, other Treating Professionals, etc.)

Brief Treatment Plan
Although soft tissue injuries heal at variable rates, depending upon the extent of injury, reasonable treatment can generally be delivered over a 4-6 week period for Grade I – II (mild) WAD, a 6-8 week period for Grade II (moderate) WAD and an 8-12 week period for Grade II (severe) to  Grade III WAD.

The average length of treatment is 12 sessions. A typical treatment plan might consist of the following number of sessions, each at least one hour in length including hands-on treatment and supervised exercise:
Week 1 – 3 sessions    Week 4 – 2 sessions
Week 2 – 3 sessions    Week 5 – 1 session
Week 3 – 2 sessions    Week 6 – 1 session

Long-Term Goals for this client
The long-term goals are similar to the short-term goals.  The focus, however, is less on pain and more on the restoration of normal function. Since the patient is likely in the re-modeling phase of tissue healing, it is critical that re-activation occur in order to restore to normal strength and elasticity of the tissues

One of the primary long-term goals is to promote self-efficacy, as there is no research supporting extended periods of passive treatment.  Long term treatment can promote dependency of the patient on the treating professional and can actually prolong recovery.

Similarly, there is considerable research to support early return to work and function in order to minimize chronicity and prevent the physical, psychological and chemical changes which lead to a patient’s perception and experience of disability or impairment.

More information or comments about referral and/or a multi-disciplinary approach with other health care professionals in the treatment of musculoskeletal injury
Although the focus of physiotherapy treatment in the initial stage is re-activation, there are several physical modalities that may assist in creating optimal conditions
for healing. Although there is no way to speed the body’s natural healing process, the treatment is still aimed at
maximizing the ideal conditions for the tissues’ own regenerative capability.

Physical modalities may include those:

• generating heat or mechanical effects in the tissues (e.g. hot packs, laser, ultrasound, short wave diathermy)
• using the special properties of electrical currents or the electromagnetic spectrum in an athermic mode (e.g. interferential currents, pulsed athermic shortwaves, transcutaneous electrical nerve stimulation, or direct currents)
• recording and stimulating motor nerves and muscle (e.g. modifications of the muscle-stimulating currents, sinusoidal waves, and electromyographic biofeedback units)

The Physiotherapist requires a sound understanding of the pathophysiologic processes in order to identify the rational use for one or more of these modalities in the subacute phase of inflammation.

To achieve optimal response, there should be:

• early intervention to minimize the development of chronic pathologic changes in tissues
• accurate assessment and diagnosis of the condition, which allows correct therapeutic decisions and realistic prognosis
• appropriate, measurable and goal-oriented treatment
• objective and functional assessment that takes into account the individual’s vocational and recreational
• activities
• liaison with the employer and insurer to ensure a plan for a safe, graduated return to activity to minimize the risk of re-injury

If objective signs and symptoms persist beyond the first 4-6 weeks, or if the objective signs resolve but the individual has not yet resumed his or her functional activities, consideration should be given to one or more of the following options:

• further medical investigation by a physician or specialist
• development of an alternate treatment plan
• referral to an activation program (i.e. exercise therapy/work conditioning)
• referral to an alternate professional (i.e. MT, OT, Case Manager, etc.)
• referral to a multi-disciplinary treatment program

Other Relevant Information
A comprehensive literature review on Whiplash Associated Disorder (WAD) was recently conducted by Therese Leigh, M.Sc.P.T. with the support of the Physiotherapy Association of British Columbia (PABC). The consensus of this document, Clinical Practice Guideline for Physiotherapy Treatment of Patients with Whiplash Associated Disorder, is that there is strong evidence supporting the use of education, range of motion exercises, manual therapy and exercise. There is little consensus on the use of electrotherapy and other modalities and it is recommended that they be used as adjuncts to active treatment only.

A full version of this project can be obtained through the Physiotherapy Association of British Columbia.