Background & Aims
Years after injury, up to 50% of people with whiplash-associated disorders (WAD) still report persistent disability and neck pain [1-3]. Whiplash injury is the most frequent injury in car accidents and affects 43.8% of the individuals involved (2). Improving neck-related functioning is essential, as individuals with WAD have weaker neck muscles (4), more restricted cervical range of motion (5), reduced neck muscle endurance and more disability (6) than patients with non-traumatic neck pain. Neck-specific exercises supervised by a physiotherapist twice a week for 12 weeks (NSE) have shown improved neck-related function (7,8), but the effect of exercises delivered via the internet is unknown. The aim of this study was to evaluate the effects of two different ways to deliver neck-specific exercises: NSE supervised by a physiotherapist for 12 weeks and the same exercises with internet support and four physiotherapist sessions (NSEIT), on cervical range of motion and neck muscle endurance
Methods
This was a prospective, multi-centre, assessor-blinded randomised controlled study with a planned secondary analysis of neck-related function (active cervical range of motion [ACROM], cranio-cervical flexion test [CCFT], ventral and dorsal neck muscle endurance [NME] and neck pain intensity measured immediately after the dorsal NME test. The study included participants with chronic WAD grade II (i.e., neck pain and clinical musculoskeletal signs) or III (i.e., grade II plus neurological signs), with a whiplash injury at least six months but not more than five years prior to study entry, aged 18–63 years, with an average neck pain intensity over the past week > 20 mm according to a 100-mm Visual Analog Scale (VAS), and >20 on the Neck Disability Index (NDI, 0–100). Outcomes were changes in ACROM, CCFT, NME and neck pain intensity measured at baseline and at 3- and 15-month follow-ups. The analyses were conducted on an intention-to-treat basis.
Results
In total, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70). In the NSEIT group, 61 (87%) and 50 (71%) participants were followed up during 3- and 15-month tests, respectively. In the NSE group, 59 (84%) and 50 (71%) participants were followed up during 3- and 15-month tests, respectively. There were no significant differences in baseline variables between the groups (p ? 0.15).
There was no significant main effect of differences between the NSEIT and NSE groups, but a significant group-by-time interaction effect did in ACROM flexion/extension. The NSEIT group improved to 3-month follow-up, but the NSE group did not. However, both groups improved to 15-month follow-up. Both groups also improved significantly over time in all other outcomes (p<0.001) at 3- and 15-month follow-ups, with effect size between 0.64 and 1.35 in ACROM, CCFT, dorsal NME and neck pain, and effect size between 0.22 and 0.42 in ventral NME.
Conclusions
Both NSE and NSEIT could be used as a treatment for patients with chronic WAD to improve neck function. The results were sustained at 15-month follow-up for both NSE and NSEIT, so either could be used to treat chronic WAD, responding to the need for increased flexibility and the availability of effective exercise interventions. Neck pain intensity measured immediately after the dorsal NME test was significantly decreased in both groups after three months of neck-specific exercises, and the results were sustained at 15-month follow-up, indicating improvements in tolerating loading to the neck.
References
1. Carroll LJ, Holm LW, Hogg-Johnson S, Cote P, Cassidy JD, Haldeman S, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. J Manipulative Physiol Ther. 2009;32(2 Suppl):S97-S107. https://doi.org/10.1016/j.jmpt.2008.11.014
2. Gustafsson M, Stigson H, Krafft M, Kullgren A. Risk of permanent medical impairment (RPMI) in car crashes correlated to age and gender. Traffic Injury Prevention. 2015;16(4):353-61. https://doi.org/10.1080/15389588.2014.940459
3. Shearer HM, Carroll LJ, Côté P, Randhawa K, Southerst D, Varatharajan S, et al. The course and factors associated with recovery of whiplash-associated disorders: an updated systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. Eur J Physiother. 2021;23(5):279-94. https://doi.org/10.1080/21679169.2020.1736150
4. Krogh S, Kasch H. Whiplash injury results in sustained impairments of cervical muscle function: a one-year prospective, controlled study. J Rehabil Med. 2018;50(6):548-55. https://doi.org/10.2340/16501977-2348
5. Stenneberg MS, Rood M, de Bie R, Schmitt MA, Cattrysse E, Scholten-Peeters GG. To what degree does active cervical range of motion differ between patients with neck pain, patients with whiplash, and those without neck pain? A systematic review and meta-analysis. Arch Phys Med Rehabil. 2017;98(7):1407-34. https://doi.org/10.1016/j.apmr.2016.10.003
6. Stenneberg MS, Scholten-Peeters GGM, den Uil CS, Wildeman ME, van Trijffel E, de Bie RA. Clinical characteristics differ between patients with non-traumatic neck pain, patients with whiplash-associated disorders, and pain-free individuals. Physiother Theory Pract. 2021:1-11. https://doi.org/10.1080/09593985.2021.1962464
7. Peterson GE, Landen Ludvigsson MH, O’Leary SP, Dedering AM, Wallman T, Jonsson MI, et al. The effect of 3 different exercise approaches on neck muscle endurance, kinesiophobia, exercise compliance, and patient satisfaction in chronic whiplash. J Manipulative Physiol Ther. 2015;38(7):465-76 e4. https://doi.org/10.23736/S1973-9087.21.06518-7
8. Peterson G, Landen Ludvigsson M, Peolsson A. Neck-related function and its connection with disability in chronic whiplash-associated disorders: secondary analysis of a randomized controlled study. Eur J Phys Rehabil Med. 2021;57(4):607-19. https://doi.org/10.1016/j.jmpt.2015.06.011
9. Peolsson A, Landen Ludvigsson M, Peterson G. Neck-specific exercises with internet-based support compared to neck-specific exercises at a physiotherapy clinic for chronic whiplash-associated disorders: study protocol of a randomized controlled multicentre trial. BMC Musculoskelet Disord. 2017;18(1):524. https://doi.org/10.1186/s12891-017-1853-1
10. Peolsson A, Hermansen A, Peterson G, Nilsing Strid E. Return to work a bumpy road: a qualitative study on experiences of work ability and work situation in individuals with chronic whiplash-associated disorders. BMC Public Health, 2021. 21(1): p. 785. https://doi.org/10.1186/s12889-021-10821-w
Presenting Author
Gunnel Peterson
Poster Authors
Gunnel Peterson
PhD
Centre of clinical research Sörmland, Uppsala University
Lead Author
Emma Nilsing-Stridh
RPT & Associate professor
University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro
Lead Author
Margaretha Jönsson
MSc
Centre for Clinical Research Sörmland, Eskilstuna, Sweden.
Lead Author
Jesper Hävermark
BSc
Centre for Clinical Research, Development and Education, County Council Uppsala, Sweden
Lead Author
Anneli Peolsson
PhD
Linköping University Faculty of Health sciences
Lead Author
Topics
- Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science