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Neck-specific exercise with or without a behavioural approach, or prescription of physical activity in chronic whiplash associated disorders
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-3259-3133
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Although 50% of those who suffer a whiplash injury still report neck pain after one year, there is a lack of knowledge about effective treatment for chronic whiplash associated disorders (WAD). Exercise is potentially useful, but the response to exercise in chronic WAD is highly variable between individuals and factors associated with good outcomes as well as the cost-effectiveness are unknown.

Aim: The general aim of this thesis was to evaluate the effect on  self-reported disability/ functioning, pain and selfefficacy of three different exercise interventions in chronic WAD grade 2 and 3, and to determine the cost-effectiveness of these interventions.

Material and methods: A total of 216 participants with chronic WAD took part in this randomized, assessor blinded, controlled, clinical trial. Participants were randomized to either neck-specific exercise without (NSE), or with a behavioural approach (NSEB), or prescription of physical activity (PPA) for 12 weeks. Evaluations of change scores and proportion of clinically relevantly improved participants regarding disability/functioning (Neck Disability Index (NDI)/Patient Specific Functional Scale (PSFS)), pain (Visual Analogue Scale of current neck pain (VAS-P), pain bothersomeness (VAS-B)) and Self-efficacy (Self-Efficacy Scale (SES)) were made after 3, 6, 12 and 24 months. Secondary analyses were made, regarding factors associated with clinically relevant improvements in disability, pain and regarding cost-effectiveness.

Results: Disability was more improved in the NSE/NSEB groups (NDI, P=0.02) than the PPA group, which reported no improvement, at 3 and 6 months, results remaining at 12 and 24 months (p ≤ 0.02). Functioning (PSFS) was also more improved in the NSE/NSEB groups than the PPA group at 3 months, in the NSEB compared to the PPA group at 6 months, and the NSE compared to the PPA groups at 12 and 24 months. The proportion of participants reaching clinically relevant improvement regarding NDI and PSFS was also larger in the NSE/NSEB groups at all time points (P<0.05), except NDI at 3 months and PSFS at 24 months. There were no differences between groups in VAS-P, VASB or SES change scores. The proportion of participants with clinically relevant reduction in VAS-P and VAS-B was however higher (P<0.02) in the NSE/NSEB groups compared with the PPA group at 3 and 12 months. Self-efficacy was only improved in the NSE group but without any between-group differences. There were no significant differences in any outcomes between the NSE/NSEB groups.

The only significant factor associated with both clinically relevant improvements in disability and neck pain both at 3 and 12 months was participation in the NSE group, with odds up to 5.3 times higher than in the PPA group. Different baseline features were associated with the improvements depending on the outcome and time point examined. From a societal perspective, NSE was the cost-effective option.

Conclusion: Physiotherapist-led neck-specific exercise resulted in better outcomes than prescription of physical activity regarding disability, functioning, and pain. The observed benefits of adding a behavioural approach to neck-specific exercise were inconclusive, and NSE was the cost-effective option from a societal perspective. Factors associated with clinically relevant improvements after exercise interventions in chronic WAD differed whether disability or neck pain was the outcome, but also differed in the short and long term. Participation in the NSE group was the only factor associated with both outcomes after both 3 and 12 months.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016. , 82 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1509
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:liu:diva-126782DOI: 10.3384/diss.diva-126782ISBN: 978-91-7685-839-4 (print)OAI: oai:DiVA.org:liu-126782DiVA: diva2:917053
Public defence
2016-05-20, Berzeliussalen, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish Research CouncilRegion ÖstergötlandMedical Research Council of Southeast Sweden (FORSS)
Available from: 2016-04-05 Created: 2016-04-05 Last updated: 2016-04-06Bibliographically approved
List of papers
1. The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders: A Randomized Clinical Trial
Open this publication in new window or tab >>The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders: A Randomized Clinical Trial
Show others...
2015 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 31, no 4, 294-303 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim of this study was to compare the effect on self-rated pain, disability, and self-efficacy of 3 interventions for the management of chronic whiplash-associated disorders: physiotherapist-led neck-specific exercise (NSE), physiotherapist-led NSE with the addition of a behavioral approach, or Prescription of Physical Activity (PPA). Materials and Methods: A total of 216 volunteers with chronic whiplash-associated disorders participated in this randomized, assessor blinded, clinical trial of 3 exercise interventions. Self-rated pain/pain bothersomeness (Visual Analogue Scale), disability (Neck Disability Index), and self-efficacy (Self-Efficacy Scale) were evaluated at baseline and at 3 and 6 months. Results: The proportion of patients reaching substantial reduction in pain bothersomness (at least 50% reduction) was more evident (P less than 0.01) in the 2 NSE groups (29% to 48%) compared with the PPA group (5%) at 3 months. At 6 months 39% to 44% of the patients in the 2 neck-specific groups and 28% in the PPA group reported substantial pain reduction. Reduction of disability was also larger in the 2 neck-specific exercise groups at both 3 and 6 months (P less than 0.02). Self-efficacy was only improved in the NSE group without a behavioral approach (P = 0.02). However, there were no significant differences in any outcomes between the 2 physiotherapist-led NSE groups. Discussion: NSE resulted in superior outcomes compared with PPA in this study, but the observed benefits of adding a behavioral approach to the implementation of exercise in this study were inconclusive.

Place, publisher, year, edition, pages
Lippincott, Williams andamp; Wilkins, 2015
Keyword
chronic; whiplash; exercise; disability; pain
National Category
Medical and Health Sciences Health Sciences Physiotherapy
Identifiers
urn:nbn:se:liu:diva-116944 (URN)10.1097/AJP.0000000000000123 (DOI)000350986000002 ()24918474 (PubMedID)
Note

Funding Agencies|Swedish government through the Swedish Research Council; Swedish Social Insurance Agency through the REHSAM foundation Stockholm, Sweden; Sormland, Sweden County Council; Uppsala, Sweden County Council; Swedish Research Council, Stockholm, Sweden; Health Practitioner Research Fellowship (Queensland Health); Health Practitioner Research Fellowship (University of Queensland, Brisbane, Australia [NHMRC CCRE Spinal Pain, Injury and Health])

Available from: 2015-04-13 Created: 2015-04-10 Last updated: 2017-12-04
2. Factors associated with pain and disability reduction following exercise interventions in chronic whiplash
Open this publication in new window or tab >>Factors associated with pain and disability reduction following exercise interventions in chronic whiplash
Show others...
2016 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 20, no 2, 307-315 p.Article in journal (Refereed) Published
Abstract [en]

BackgroundSome studies support the prescription of exercise for people with whiplash-associated disorders (WAD); however, the response is highly variable. Further research is necessary to identify factors which predict response. MethodsThis is a secondary analysis of a randomized, multicentre controlled clinical trial of 202 volunteers with chronic WAD (grades 2 and 3). They received either neck-specific exercise with, or without a behavioural approach, or prescription of physical activity for 12weeks. Treatment response, defined as a clinical important reduction in pain or disability, was registered after 3 and 12months, and factors associated with treatment response were explored using logistic regression. ResultsParticipation in the neck-specific exercise group was the only significant factor associated with both neck pain and neck disability reduction both at 3 and 12months. Patients in this group had up to 5.3 times higher odds of disability reduction and 3.9 times higher odds of pain reduction compared to those in the physical activity group. Different baseline features were identified as predictors of response depending on the time point examined and the outcome measure selected (pain vs. disability). ConclusionFactors associated with treatment response after exercise interventions differ in the short and long term and differ depending on whether neck pain or disability is considered as the primary outcome. Participation in a neck-specific exercise intervention, in contrast to general physical activity, was the only factor that consistently indicated higher odds of treatment success. These results support the prescription of neck-specific exercise for individuals with chronic WAD.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2016
National Category
Health Sciences Medical and Health Sciences Physiotherapy
Identifiers
urn:nbn:se:liu:diva-125302 (URN)10.1002/ejp.729 (DOI)000368819500016 ()26031995 (PubMedID)
Note

Funding Agencies|Swedish government through the REH-SAM Foundation; Clinical Research of Ostergotland Council; Clinical Research of Sormland County Council; Medical Research Council of Southeast Sweden; Uppsala-O rebro Regional Research Council Sweden; Swedish Research Council

Available from: 2016-02-24 Created: 2016-02-19 Last updated: 2017-11-30
3. One- and two-year follow-up of a randomized trial of neck-specific exercise with or without a behavioural approach compared with prescription of physical activity in chronic whiplash disorder
Open this publication in new window or tab >>One- and two-year follow-up of a randomized trial of neck-specific exercise with or without a behavioural approach compared with prescription of physical activity in chronic whiplash disorder
2016 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 48, no 1, 56-64 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To explore whether neck-specific exercise, with or without a behavioural approach, has benefits after 1 and 2 years compared with prescribed physical activity regarding pain, self-rated functioning/disability, and self-efficacy in management of chronic whiplash. Design: Follow-up of a randomized, assessor blinded, clinical trial. Patients: A total of 216 volunteers with chronic whiplash associated disorders, grades 2 or 3. Methods: Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise with or without a behavioural approach, or physical activity prescription. Self-rated pain (visual analogue scale), disability/functioning (Neck Disability Index/Patient Specific Functional Scale) and self-efficacy (Self-Efficacy Scale) were evaluated after 1 and 2 years. Results: Both neck-specific exercise groups maintained more improvement regarding disability/functioning than the prescribed physical activity group at both time-points (p &lt;= 0.02). At 1 year, 61% of subjects in the neck-specific group reported at least 50% pain reduction, compared with 26% of those in the physical activity prescription group (p &lt; 0.001), but at 2 years the difference was not significant. Conclusion: After 1-2 years, participants with chronic whiplash who were randomized to neck-specific exercise, with or without a behavioural approach, remained more improved than participants who were prescribed general physical activity.

Place, publisher, year, edition, pages
FOUNDATION REHABILITATION INFORMATION, 2016
Keyword
whiplash; chronic; exercise; randomized; follow-up study; spine; behaviour therapy
National Category
Health Sciences Physiotherapy
Identifiers
urn:nbn:se:liu:diva-126145 (URN)10.2340/16501977-2041 (DOI)000370307600009 ()26660722 (PubMedID)
Note

Funding Agencies|Swedish government through the REHSAM Foundation; Swedish Research Council; regional Center for Clinical Research; County Council of Ostergotland; Centre for Clinical Research Sormland at Uppsala University; Medical Research Council of Southeast Sweden; Uppsala-Orebro Regional Research Council, Sweden

Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2017-11-30

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Landén Ludvigsson, Maria

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