Background: Neck-specific exercises (NSE) supervised by a physiotherapist twice a week for 12 weeks have shown good results in chronic whiplash-associated disorders (WADs), but the effect of exercise delivered via the internet is unknown. Objective: This study examined whether NSE with internet support (NSEIT) and 4 physiotherapy sessions for 12 weeks were noninferior to the same exercises supervised by a physiotherapist twice a week for 12 weeks (NSE). Methods: In this multicenter randomized controlled noninferiority trial with masked assessors, we recruited adults aged 18-63 years with chronic WAD grade II (ie, neck pain and clinical musculoskeletal signs) or III (ie, grade II plus neurological signs). Outcomes were measured at baseline and at 3-and 15-month follow-ups. The primary outcome was change in neck-related disability, measured with the Neck Disability Index (NDI; 0%-100%), with higher percentages indicating greater disability. Secondary outcomes were neck and arm pain intensity (Visual Analog Scale [VAS]), physical function (Whiplash Disability Questionnaire [WDQ] and Patient-Specific Functional Scale [PSFS]), health-related quality of life (EQ-5D-3L and EQ VAS), and self-rated recovery (Global Rating Scale [GRS]). The analyses were conducted on an intention-to-treat basis and with the per-protocol approach as sensitivity analyses. Results: Between April 6, 2017, and September 15, 2020, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70); 63 (90%) and 64 (91%), respectively, were followed up at 3 months, and 56 (80%) and 58 (83%), respectively, at 15 months. NSEIT demonstrated noninferiority to NSE in the primary outcome NDI, as the 1-sided 95% CI of the mean difference in change did not cross the specified noninferiority margin (7 percentage units). There were no significant between-group differences in change in NDI at the 3-or 15-month follow-up, with a mean difference of 1.4 (95% CI -2.5 to 5.3) and 0.9 (95% CI -3.6 to 5.3), respectively. In both groups, the NDI significantly decreased over time (NSEIT: mean change -10.1, 95% CI -13.7 to -6.5, effect size=1.33; NSE: mean change -9.3, 95% CI -12.8 to -5.7, effect size=1.19 at 15 months; P<.001). NSEIT was noninferior to NSE for most of the secondary outcomes except for neck pain intensity and EQ VAS, but post hoc analyses showed no differences between the groups. Similar results were seen in the per-protocol population. No serious adverse events were reported. Conclusions: NSEIT was noninferior to NSE in chronic WAD and required less physiotherapist time. NSEIT could be used as a treatment for patients with chronic WAD grades II and III.

Background: The underlying pathophysiological mechanisms of chronic Whiplash Associated Disorders (WAD) are not fully understood. More knowledge of morphology is needed to better understand the disorder, improve diagnostics and treatments. The aim was to investigate dorsal neck muscle volume (MV) and muscle fat infiltration (MFI) in relation to self-reported neck disability among 30 participants with chronic WAD grade II-III compared to 30 matched healthy controls.

Methods: MV and MFI at spinal segments C4 through C7 in both sexes with mild- to moderate chronic WAD (n = 20), severe chronic WAD (n = 10), and age- and sex matched healthy controls (n = 30) was compared. Muscles: trapezius, splenius, semispinalis capitis and semispinalis cervicis were segmented by a blinded assessor and analyzed.

Results: Higher MFI was found in right trapezius (p = 0.007, Cohen’s d = 0.9) among participants with severe chronic WAD compared to healthy controls. No other significant difference was found for MFI (p = 0.22–0.95) or MV (p = 0.20–0.76).

Conclusions: There are quantifiable changes in muscle composition of right trapezius on the side of dominant pain and/or symptoms, among participants with severe chronic WAD. No other statistically significant differences were shown for MFI or MV. These findings add knowledge of the association between MFI, muscle size and self-reported neck disability in chronic WAD.

Background Exercise in the management of persistent whiplash often doesnt specifically address dizziness. This study aimed to determine cervical musculoskeletal and sensorimotor measures, quality of life and psychological factors associated with the presence of dizziness in individuals with persistent whiplash 12 months post exercise intervention commencement. Methods A retrospective cross sectional review of questionnaires on dizziness, physical and psychological disability, quality of life and physical measures prospectively collected from 172 individuals during a randomised controlled trial. Associations between dizziness at 12 months post intervention and possible predictors was analysed with simple and multiple logistic regression models. Results Sixty-three % reported dizziness with a mean University of California Los Angeles dizziness score of 9 (SD 5) and dizziness intensity during activity of 26 mm (SD 24). They had poorer performance on sharpened Rhomberg, Neck muscle endurance (NME), and range of motion, elevated scores on pain, Neck disability index (NDI) and psychological and quality of life measures compared to those without dizziness. Less improvement in NDI and NME flexion from baseline to 12 months post exercise commencement, along with some baseline covariates were related to persistent dizziness and explained 50% of the variance. Conclusion Dizziness following exercise at 12 months post follow-up was associated with lack of improvement in NDI and NME flexion suggesting a cervicogenic role. Alternatively, the presence of dizziness may inhibit exercise response. Additional causes or contributing factors of dizziness should be investigated in those with persistent whiplash to improve quality of life.

This study investigates whether baseline pain extent, extracted from an electronic pain drawing, is an independent predictive factor of pain and disability measured 1 year and 2 years later in people with chronic WAD. Participants completed questionnaires assessing neck pain intensity, disability via the Neck Disability Index (NDI), psychological features, and work ability. Participants also completed electronic pain drawings from which their pain extent was extracted. A two-step modelling approach was undertaken to identify the crude and adjusted association between pain extent and NDI measured at 1-year and 2-year follow-ups. A total of 205 participants were included in the analysis. The univariate analysis showed that pain extent was significantly associated with the NDI score at the 1-year (p = 0.006, 95% CI: 0.159-0.909) and 2-year (p = 0.029, 0.057-0.914) follow-ups. These associations were not maintained when we introduced perceived disability, psychological health, and work ability into the model after 1 year (p = 0.56, 95%CI: -0.28-0.499) and 2 years (p = 0.401, -0.226-0.544). Pain extent, as an independent factor, was significantly associated with perceived pain and disability in patients with chronic WAD for up to 2 years. This association was masked by neck disability, psychological health, and work ability.

Background: Persistent pain and disability in whiplash-associated disorders (WAD) grades II and III are common. In two randomized controlled trials (RCTs) of neck-specific exercises (NSE), we have seen promising results in chronic WAD, with a sustained clinically important reduction in pain and disability. NSE can also be delivered through internet support (NSEIT) and a few visits to a physiotherapist, saving time and cost for both patients and providers. NSE have been shown to have positive effects in other neck pain disorders and we will evaluate the diffusion of the exercises to other patients. The aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of NSEIT and NSE in clinical practice.

Methods: The proposed study is a prospective cluster-randomized mixed-design study with hybrid 2 trial design. Reg. physiotherapists working in twenty physiotherapy clinics will be included. The primary implementation outcome is proportion of patients with neck pain receiving neck-specific exercise. Secondary outcomes are; physiotherapists attitudes to implementation of evidence-based practice, their self-efficacy and confidence in performing NSEIT/NSE, number of patients visits, and use of additional or other exercises or treatment. To further evaluate the implementation strategy, two qualitative studies will be performed with a sample of the physiotherapists. The primary outcome in the patient effectiveness evaluation is self-reported neck disability according to the Neck Disability Index (NDI). Secondary outcomes are pain intensity in the neck, arm, and head; dizziness; work- and health-related issues; and patients improvement or deterioration over time. All measurements will be conducted at baseline and at 3 and 12 months. Physiotherapists self-efficacy and confidence in diagnosing and treating patients with neck pain will also be evaluated directly after their instruction in NSEIT/NSE.

Discussion: This trial will evaluate the implementation strategy in terms of adoption of and adherence to NSEIT and NSE in clinical primary health care, and measure diffusion of the method to other patients. In parallel, the effectiveness of the method will be evaluated. The results may guide physiotherapists and health care providers to sustainable an effective implementation of effective exercise programs.

BackgroundObjective Studies of cross-sectional area (CSA) (morphology) and muscle fat infiltration (MFI) (composition) in ventral neck muscles is scarce in patients with chronic whiplash associated disorders (WAD), especially for men and those with severe WAD compared with matched healthy controls. The aim was to compare CSA and MFI of sternocleidomastoid (SCM), longus capitis (LCA) and longus colli (LCO) in patients with chronic right-sided dominant moderate (Neck Disability Index: NDI < 40) or severe WAD (NDI >= 40), compared to age- and sex-matched healthy controls. Methods Cross-sectional case-control study with blinded investigators. Thirty-one patients with chronic WAD (17 women and 14 men, mean age 40 years) (SD 12.6, range 20-62)) and 31 age- and sex-matched healthy controls underwent magnetic resonance imaging of ventral neck muscles segmental level C4. Results Unique to the severe group was a larger magnitude of MFI in right SCM (p = 0.02) compared with healthy controls. There was no significant difference between the groups with regards to the other muscles and measures. Conclusions Individuals with severe right-sided dominant WAD have a higher MFI in the right SCM compared to healthy controls. No other differences were found between the groups. The present study indicates that there are changes in the composition of muscles on the side of greatest pain.

Neck disorders are common in primary health care (PHC) physiotherapy. A neck-specific exercise program based on research findings was implemented among physiotherapists in Swedish PHC. The aim of the study was to evaluate the adoption of the program. We invited PHC physiotherapists to an educational session including theoretical information and practical training. Before the educational session the participants (n = 261) completed a baseline questionnaire. After 3 and 12 months, we distributed surveys to identify changes in practice and in confidence regarding diagnosis and treatment. We compared data from 3-months and 12-months follow-up, respectively, with baseline data. Self-reported frequency of most of the included assessment methods was unchanged after 12 months. Frequency of assessment of neck proprioception had increased significantly. Specific neck muscle exercise for treatment of whiplash associated disorders was applied more frequently after 3 and after 12 months than at baseline. Frequency of other treatment methods remained unchanged. Confidence in diagnosis and treatment increased significantly, particularly among women. The program was not adopted as expected, but resulted in increased confidence regarding diagnosis and treatment. The provision of a short educational session seemed not to be sufficient to obtain a sustained change in practice.

Objective: The objective of this study was to evaluate an extended role for the physiotherapist in primary care in referring patients to plain X-ray. Methods: This prospective cohort study was set in a single region in Sweden. It included 20 physiotherapists who were educated in a 1-day training in performing referral to X-ray, along with 107 patients with musculoskeletal disorders who were referred to X-ray. We evaluated referral quality and patient and physiotherapist satisfaction and calculated healthcare and patient costs. Results: All referrals fulfilled the basic requirements of quality, and 78% were classified as good, fulfilling all criteria. Both patients and physiotherapists were satisfied with the extended role for the physiotherapist that decreased the waiting time to diagnosis and to adequate treatment. Costs were reduced for patients (by _53/patient) and healthcare (by _6286.2/107 patients). The cost to visit a physician was twice that of a physiotherapist visit. Conclusions: An extended role for physiotherapists in primary care in referring patients to X-ray was effective and safe for patients and reduced costs for patients and for healthcare. Physiotherapists in primary care were able to refer patients to X-ray after a 1 day of training, and the extended role freed up 45 min of physician time for each patient with a musculoskeletal disorder in need of an X-ray.

Background Neck and shoulder pain is common in the general population, but studies on factors related to the risk of neck and shoulder pain have produced inconclusive results. Known factors related to pain include general physical activity, exercise, sleep disorders, and lifestyle, but further research is needed to improve our ability to prevent neck and shoulder pain. The aim was to investigate whether neck and shoulder pain are associated with physical domains (i.e., aerobic physical activities, general physical activities, and sitting time), sleep disturbances, general health, job satisfaction, and/or working time. Methods This population-based, cross-sectional study was conducted in Sweden in 2017 and included 16,167 individuals, aged 18 to 63 years. We administered a questionnaire to determine neck and shoulder pain, the time spent in general physical activity or aerobic physical activity, the time spent sitting, sleep disturbances, general health, job satisfaction, and the time spent working. Factors associated with neck and shoulder pain were explored using logistic regression. Results Significant factors associated with neck and shoulder pain were: overall health, sleep quality, and aerobic exercise. The odds of sustaining neck and shoulder pain increased with moderate or poor health (odds ratios [ORs]: 2.3 and 2.8, respectively) and sleep disorders (OR: 1.7). Conversely, aerobic physical activity performed more than 60 min/week at a level that enhanced respiratory and heart rate was associated with a reduced risk of experiencing neck and shoulder pain (OR: 0.8). Conclusions Although no causal relationships could be determined in the present study, the results highlight important associations between aerobic exercise, undisturbed sleep, good health, and the absence of upper body pain. Exercises that enhance breathing and heart rate were associated with a reduced risk of experiencing neck or shoulder pain, but there was no association between general physical activity and upper body pain. Therefore, clinicians may not recommend low-intensity activities, such as walking, for preventing or improving neck and shoulder pain.

BACKGROUND: More than 40% of individuals with whiplash injury experience persistent neck pain and disability years later, called whiplash-associated disorders (WAD). A randomized controlled trial evaluated three exercise interventions in WAD and found that neck-specific exercise (NSE) and NSE with a behavioral approach (NSEB) significantly improve disability compared to prescribed physical activity (PPA). However, the relationship between neck-related function and disability is inconclusive and needs to be further investigated. AIM: The present study compares the effect of NSE, NSEB, and PPA on neck muscle endurance (NME), active cervical range of motion (AROM), grip strength, and pain intensity immediately before and after the physical tests, and neck disability in individuals who are below or above the cut-off for normative reference values regarding NME, AROM, and grip strength. DESIGN: Follow-up to a multicenter randomized clinical trial. SETTING: Primary healthcare centers and hospital outpatient services. POPULATION: The selected population of this study included 216 patients with persistent WAD grades II and III. METHODS: This is a secondary analysis including 12 months follow-up. NME, AROM, grip strength, pain, and self-reported disability were recorded at baseline, 3, 6, and 12 months. Linear mixed models were used, and sub-group analyses evaluated by non-parametric tests. RESULTS : NSE and NSEB resulted in greater improvements compared to PPA (P<0.01) in ventral (only males) and dorsal NME, AROM, and pain intensity during testing. We found no significant between-group differences in grip strength and no significant differences between the NSE and NSEB groups. Improvement in disability was seen at the 12-month follow-up of NSE and/or NSEB for individuals both below and above the cut-off reference values for NME and AROM. Individuals in the PPA group below the reference values for NME and AROM reported increasing disability at 12 months compared to baseline. CONCLUSIONS: The results suggest that neck-specific exercises (i.e., NSE, NSEB) improve clinical function and decrease disability in chronic WAD compared to PPA, but PPA can increase disability for patients with low neck-related function. CLINICAL REHABILITATION IMPACT : Higher neck-related function seems to be important for reduced disability in persistent WAD grades II and III. Neck-specific exercises could lead to higher neck-related function.

Background Work resumption is a big challenge in the rehabilitation process for individuals with whiplash-associated disorders (WAD). To better meet the needs of individuals with WAD in their return to work process, more knowledge on their experiences and perspectives is needed. The aim of this study was to explore the experiences of work ability and the work situation of individuals who participated in a neck-specific exercise programme for chronic WAD. Methods This qualitative study has an exploratory and descriptive design based on data collected through open-ended interviews with 17 individuals with chronic WAD. Data were analysed inductively using conventional content analysis. Results Analysis of the data yielded the following five categories related to the participants narratives on their experiences of work ability and their work situation: Return to work - a process of setbacks and bureaucracy; The need to be understood by health care professionals, and to receive a treatment plan; Individual resources are important for work ability; The consequences of reduced work ability; and Working conditions are important for work ability. Conclusion Individuals with chronic WAD often struggle to return to work. Emotional and practical support from stakeholders is imperative and needs to be strengthened. Participating in a neck-specific exercise programme, including being acknowledged and receiving information about WAD, could positively affect the work ability of WAD sufferers. This study has provided management strategies to improve the ability to work for individuals with chronic WAD, and highlights the need to incorporate a healthy and sustainable return to work in the rehabilitation of individuals with WAD, thereby making their return to work a success.

Up to 90% of people with neurological deficits following whiplash injury report chronic symptoms. A recent unique study of neck-specific exercise showed positive results (post-intervention at 12 weeks), regarding arm pain and neurological deficits in people with chronic whiplash associated disorders (WAD). This 1-year follow-up of that randomised controlled study with assessor blinding aimed to examine whether neck-specific exercise with (NSEB) or without (NSE) a behavioural approach has long-term benefits over physical activity prescription (PPA) regarding arm pain and neurological deficits (n=171). Interventions were: NSE, NSEB, or PPA. Follow-up of arm pain, paraesthesia bothersomeness (questionnaires) and clinical neurological tests were performed after 3, 6 and 12 months and analysed with Linear Mixed Models and General Estimating Equations. The NSE and/or NSEB groups reported significantly less pain and paraesthesia bothersomeness as well as higher odds of normal key muscle arm strength and of normal upper limb neural tension over the year (all p<0.03), compared with PPA. In conclusion, results suggest that neck-specific exercise with or without a behavioural approach may have persisting long term benefits over PPA regarding arm pain and clinical signs associated with neurological deficits in chronic WAD.

Objectives: Neck-specific exercise can reduce neck pain and increase function, but information on how different neck muscle layers are activated during neck exercises is scarce. The aim of this study was to investigate deformation and deformation rate in 5 dorsal neck muscles and the correlation among these muscles during a loaded dynamic exercise used in clinical practice. Methods: Deformation and deformation rate were investigated in 5 dorsal right-sided neck muscles in 20 individuals without neck pain using ultrasonography and speckle-tracking analyses. Repeated-measures analysis of variance was used to measure differences between the muscles, and correlations between neck muscles were analyzed with Kendalls tau. Results: Deformation in left (contralateral) rotation showed significant differences among the muscles (P = .01), with higher deformation of the semispinalis capitis muscle compared with the trapezius muscle (P = .02). There were no significant differences among the 5 neck muscles in right (unilateral) rotation (P = .46). There were significant differences in deformation rate among muscles in both right and left rotation (P < .01). The trapezius muscles have the lowest deformation rate in right rotation (P < .01). In left rotation, the trapezius and multifidus muscles showed lower deformation rates compared with most of the other muscles (P < .03). Almost all muscles were correlated in both deformation and deformation rate. Conclusion: The quadruped standing loaded dynamic neck exercise seemed to activate all the investigated neck muscles, with a tendency for more activation of the semispinalis capitis.

Background: Almost 40% of individuals with chronic whiplash-associated disorders (WAD) report headache after 5 years, making it one of the most common persistent symptoms besides neck pain, but randomized treatment studies are lacking. This study aimed to evaluate the effect of 3 different exercise approaches on headache in chronic WAD grades 2 and 3, and to identify potential factors associated with such headache, and whether they differ depending on 3 different aspects of such headache (current headache, maximum headache, or headache bothersomeness).Methods: This was an analysis of a randomized clinical trial of people with chronic WAD and headache (n = 188), who were randomized to either 12 weeks of neck-specific exercise without (NSE) or with a behavioral approach (NSEB) or physical activity prescription (PPA). Data were collected at baseline and at 3, 6, and 12 months. Physical and psychosocial factors were tested for association with headache. Multivariate regression models and linear mixed models were used.Results: The NSE/NSEB groups reported reduced headache both over time and compared to PPA. Up to 51% (NSE) and 61% (NSEB) reported at least 50% reduction in their headache at 12 months. The PPA group was not improved over time. Neck pain and dizziness were associated with headache regardless of aspect of headache. The only associated psychosocial factor was anxiety, which was associated with headache bothersomeness. Other factors were mainly physical, and up to 51% of the variance was explained.Conclusion: Headache in chronic WAD, may be reduced with neck-specific exercise with or without a behavioral approach. Chronic headache was associated with neck pain and dizziness regardless of aspect tested. Other factors associated with headache in chronic WAD were mainly physical rather than psychosocial.Trial registration number: Clinical Trials.gov, no: NCT015285

Objectives: The present studys objective was to understand the causal mechanisms underpinning the recovery of individuals with whiplash-associated disorders (WAD). We applied Bayesian Networks (BN) to answer 2 study aims: (1) to identify the causal mechanism(s) of recovery underpinning neck-specific exercise (NSE), and (2) quantify if the cyclical pathway of the fear-avoidance model (FAM) is supported by the present data. Materials and Methods: We analyzed a prospective cohort data set of 216 individuals with chronic WAD. Fifteen variables were used to build a BN model: treatment group (NSE with or without a behavioral approach, or general physical activity), muscle endurance, range of motion, hand strength, neck proprioception, pain catastrophizing, fear, anxiety, depression, self-efficacy, perceived work ability, disability, pain intensity, sex, and follow-up time. Results: The BN model showed that neck pain reduction rate was greater after NSE compared with physical activity prescription (beta=0.59 points per month [Pamp;lt;0.001]) only in the presence of 2 mediators: global neck muscle endurance and perceived work ability. We also found the following pathway of variables that constituted the FAM: anxiety, followed by depressive symptoms, fear, catastrophizing, self-efficacy, and consequently pain. Conclusions: We uncovered 2 mediators that explained the mechanisms of effect behind NSE, and proposed an alternative FAM pathway. The present study is the first to apply BN modelling to understand the causal mechanisms of recovery in WAD. In doing so, it is anticipated that such analytical methods could increase the precision of treatment of individuals with chronic WAD.

BackgroundThere is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls.MethodsParticipants are a sub-group (n=30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the butterfly test and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n=30).DiscussionThe study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD.Trial registrationClinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.

Introduction Patients suffering from remaining disability after anterior cervical decompression and fusion (ACDF) surgery for cervical disc disease may be prescribed physical activity (PPA) or neck-specific exercises (NSEs). Currently, we lack data for the success of either approach. There is also a knowledge gap concerning the use of internet-based care for cervical disc disease. The scarcity of these data, and the high proportion of patients with various degrees of incapacity following ACDF, warrant increased efforts to investigate and improve cost-effective rehabilitation. The objective is to compare the effectiveness of a structured, internet-based NSE programme, versus PPA following ACDF surgery. Methods and analysis This is a prospective, randomised, multicentre study that includes 140 patients with remaining disability (amp;gt;= 30% on the Neck Disability Index, NDI) following ACDF for radiculopathy due to cervical disc disease. Patient recruitment occurs following attendance at routine clinical appointments, scheduled at 3 months postsurgery. Patients are then randomised to one of two groups (70 patients/group) for a 3-month treatment programme/period of either internet-based NSE or PPA. Questionnaires on background data, pain and discomfort, physical and mental capacity, satisfaction with care, and health and workplace factors are completed, along with physical measures of neck-related function conducted by independent test leaders blinded to randomisation. Measures are collected at inclusion, after the 3-month treatments (end of treatment) and at a 2-year follow-up. Radiography will be completed at the 2-year follow-up. Preoperative data will be collected from the Swedish Spine Registry. Data on healthcare consumption, drug use and sick leave will be requested from the relevant national registers. Ethical considerations This study was approved by the Regional Ethical Review Board in Linkoping Ref. 2016/283-31 and 2017/91-32. The scientists are independent with no commercial ties. Patients are recruited after providing written informed consent. Patient data are presented at group level such that no connection to any individual can be made. All data are anonymised when reported, and subject to the Swedish Official Secrets Health Acts. The test leaders are independent and blinded for randomisation. Exercises, both general and neck-specific, have been used extensively in clinical practice and we anticipate no harm from their implementation other than a risk of muscle soreness. Both randomisation groups will receive care that is expected to relieve pain, although the group receiving NSE is expected to demonstrate a greater and more cost-effective improvement versu s the PPA group. Any significant harm or unintended effects in each group will be collected by the test leaders. All questionnaires and test materials are coded by the research group, with code lists stored in locked, fireproof file cabinets, housed at the university in a room with controlled (card-based) access. Only individuals in receipt of a unique website address posted by the researchers can access the programme; patients can neither communicate with each other nor with caregivers via the programme. Study participation might lead to improved rehabilitation versus non-participation, and might therefore be of benefit. The results of this study should also contribute to more effective and flexible rehabilitation, shorter waiting times, lower costs and the possibility to implement our findings on a wider level. Dissemination If effective, the protocols used in this study can be implemented in existing healthcare structures. The results of the study will be presented in scientific journals and popular science magazines of relevance to health. The findings will also be presented at local, regional, national and international conferences and meetings, as well as in the education of university students and at public lectures. Information about the results will be communicated to the general population in cooperation with patient organisations and the media.

PURPOSE: The aim was to evaluate whether neck-specific exercise, with (NSEB) or without (NSE) a behavioural approach, improves health-related quality of life (HRQoL) compared to physical activity prescription (PPA) in chronic whiplash-associated disorders (WAD) grades 2 and 3. A secondary aim was to identify factors associated with HRQoL and HRQoL improvement following exercise interventions.

METHODS: This is a secondary analysis of a multicentre randomized clinical trial. Participants (n = 216) with chronic WAD grades 2 and 3 were randomized to 12 weeks of PPA or physiotherapist-led NSE or NSEB. The EQ-5D 3L/EQ-VAS and SF-36v2 physical (PCS) and mental (MCS) component summaries were collected together with several neck-related and psychosocial outcomes at baseline, after 3, 6 and 12 months, and were analysed with linear mixed models (all time points) and multivariate linear regressions (baseline, 6 months).

RESULTS: NSE/NSEB resulted in better outcomes than PPA (EQ-VAS and SF-36 PCS, both groups, p < 0.01) but not in a higher EQ-5D score. Improvement over time was seen in EQ-5D/EQ-VAS for the NSEB group (p < 0.01), and for NSE/NSEB as measured with the PCS (p < 0.01). Factors associated with baseline HRQoL and change to 6 months in HRQoL (R² = 0.38-0.59) were both neck-related and psychosocial (e.g. depression, work ability).

CONCLUSION: Neck-specific exercise, particularly with a behavioural approach, may have a more positive impact on HRQoL than physical activity prescription in chronic WAD grades 2 and 3. HRQoL is however complex, and other factors also need to be considered. Factors associated with HRQL and improvements in HRQoL following exercise are multidimensional.

TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, No. NCT01528579.

The development of methods of non-invasive measurement of neck muscle function remains a priority in the clinical sciences. In this study, dorsal neck muscle deformation vs time curves (deformation area) were evaluated against incremental force, recorded from non-invasive real-time ultrasound measurement. The results revealed subject-specific moderate to strong linear or non-linear relationships between deformation and force. Test-retest variability showed strong reliability for all five neck muscles summed together and fair to good reliability for the five muscles evaluated separately. Multivariate statistics were used to analyse the interactions between the dorsal neck muscles during different percentages of maximal voluntary contraction (MVC). Low force (10-20% MVC) was related to muscle shortening; higher force (40-80% MVC) showed combination of shortening and elongation deformation in the muscle interactions. The muscle interactions during isometric MVC test were subject-specific, with different combinations and deformations of the five neck muscles. Force amp;gt;= 40% MVC were associated with a forward movement of the cervical spine that affected the ultrasound measurement of the dorsal neck muscles. Ultrasound with speckle-tracking analyses may be best used to detect low levels (amp;lt;40% MVC) of neck muscle activity.

Objective: Patient enablement reflects patients understanding of and coping with illness. The aim of this study was to investigate the content validity, construct validity, internal consistency and selfrated change (SRC) of the Patient Enablement Instrument (PEI) in patients with whiplash-associated disorders, cervical radiculopathy and mixed chronic pain treated in different settings. Design: Psychometric analyses. Participants: Patients with disabling non-malignant chronic musculoskeletal pain. Methods: Participants answered questionnaires on disability (Neck Disability Index (NDI) or Functional Rating Index (FRI)), anxiety/depression (Hospital Anxiety and Depression Scale; HADS) and general health (EuroQol; EQ-5D). Content validity, construct validity (confirmatory factor analysis), internal consistency and cut-off for SRC were investigated for the PEI after treatment. The SRC value was the receiver operating characteristic (ROC) curve optimal cut-off point. Results: After treatment all items were completed by 516 patients (mean standard deviation (SD) age 45.1 years (SD 10.1), women 75% (n=385)). The 1-factor PEI model had approximate fit to the data. The internal consistency Cronbachs alpha was between 0.878 and 0.929 for the 3 groups. Correlations between the PEI and the NDI/FRI, HADS and EQ-5D were fair to good. The SRCROC for whiplash-associated disorders, cervical radiculopathy and mixed chronic pain groups was 5, 6 and 4 points in the PEI, respectively. Conclusion: The PEI showed fair content validity, construct validity and internal consistency. However, the scale needs further development to improve measurement of change.

Objective The aim of this study was to investigate and compare the mechanical responses of dorsal neck muscles in individuals with whiplash-associated disorders (WAD) versus healthy individuals. Design This study included 36 individuals with WAD (26 women and 10 men) and 36 healthy controls (26 women and 10 men). Ultrasound imaging with speckle tracking was used to measure deformation and deformation rate in five dorsal neck muscles during a neck extension task. Results Compared with controls, individuals with WAD showed higher deformations of the semispinalis cervicis (P = 0.02) and multifidus (P = 0.002) muscles and higher deformation rates (P = 0.03 and 0.0001, respectively). Among individuals with WAD, multifidus deformation and deformation rate were significantly associated with pain, disability, and fatigue (r = 0.31-0.46, P = 0.0001-0.01). Conclusions These findings indicate that the mechanical responses of the deep dorsal neck muscles differ between individuals with WAD and healthy controls, possibly reflecting that these muscles use altered strategies while performing a neck extension task. This finding provides new insight into neck muscles pathology in patients with chronic WAD and may help improve rehabilitation programs. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Summarize the mechanical responses of dorsal neck muscles during loading of the neck muscles via an extension task in individuals with chronic whiplash associated disorders and healthy volunteers; (2) Differentiate mechanical responses between five dorsal neck muscles while loading the neck via an extension task; and (3) Describe the relationships between the mechanical responses of the dorsal neck muscles with the patients perception of neck pain, disability, and fatigue. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.

OBJECTIVE: To investigate the efficacy of exercise interventions and factors associated with changes in work ability for people with chronic whiplash-associated disorders.

DESIGN: Secondary analysis of a single-blind, randomized multi-centre controlled trial.

SETTING: Interventions were conducted in Swedish primary care settings.

PATIENTS: A total of 165 individuals with chronic whiplash-associated disorders grade II-III.

METHODS: Participants were randomly allocated to neck-specific exercise, neck-specific exercise with a behavioural approach, or prescribed physical activity interventions. Work ability was evaluated with the Work Ability Index at baseline, 3, 6 and 12 months.

RESULTS: The neck-specific exercise with a behavioural approach intervention significantly improved work ability compared with the prescribed physical activity intervention (3 months, p = 0.03; 6 months, p = 0.01; 12 months, p = 0.01), and neck-specific exercise at 12 months (p = 0.01). Neck-specific exercise was better than the prescribed physical activity intervention at 6 months (p = 0.05). An increase in work ability from baseline to one year for the neck-specific exercise with a behavioural approach group (p < 0.01) was the only significant within-group difference. Higher self-rated physical demands at work, greater disability, greater depression and poorer financial situation were associated with poorer work ability (p < 0.01).

CONCLUSION: This study found that neck-specific exercise with a behavioural approach intervention was better at improving self-reported work ability than neck-specific exercise or prescribed physical activity. Improvement in work ability is associated with a variety of factors.

Chronic pain and disability is common in whiplash-associated disorders (WAD), leading to personal suffering, sick leave, and social cost. The cervical spine is heavily dependent on muscular support and whiplash injury can cause damage to the neck muscles, but diagnostic tools to measure neck muscle impairment and evaluate exercise interventions are lacking. Therefore, the present study investigated ventral neck muscle interactions in 26 individuals with chronic WAD randomized to neck-specific exercise (NSE) or remaining on a waiting list (WL) in 3 months. We performed real-time, non-invasive ultrasound measurements with speckle tracking analysis and calculated the deformation area and deformation rate in three ventral neck muscles. Multivariate statistics were used to analyse interactions between the muscles. After 3 months of NSE, significant improvements were observed in neck muscle interactions and pain intensity in the NSE group compared to the WL group. Thus, this study demonstrates that non-invasive ultrasound can be a diagnostic tool for muscle impairment and used to evaluate exercise interventions in WAD and stands to make a breakthrough for better management in chronic WAD.

Up to 90% of people with neurological deficits following a whiplash injury do not recover and cervical muscle dysfunction is common. The aim of this multicentre, randomized controlled trial was to examine whether two versions of neck-specific exercise or prescription of physical activity (PPA) can improve radiating arm pain and clinical signs that can be associated with neurological deficits in people with chronic whiplash associated disorders (WAD). Participants with chronic WAD, arm symptoms and signs associated with neurological deficits (n = 171) were randomized to: 12 weeks of neck-specific exercise without (NSE) or with a behavioural approach (NSEB), or PPA. Pain/bothersomeness frequency, six measures of arm pain/paraesthesia (VAS scales), and four clinical neurological tests were evaluated after 3 months. The NSE group reported the lowest frequency and lowest levels of arm pain, the highest proportion of participants with at least 50% pain reduction and the highest proportion of normal arm muscle force. The NSEB group reported increased normal tendon reflexes. No improvements were recorded for the PPA group. Neck-specific exercise may improve arm pain and decrease signs of neurological deficits, but the addition of a behavioural approach does not seem to be of additional benefit. © 2018, The Author(s).

Background: Fifty percent of people injured by whiplash still report neck pain after 1 year and costs associated with whiplash associated disorders (WAD) are mostly attributed to health service and sick-leave costs in chronic conditions. With increasing health care expenditures the economic impact of interventions needs to be considered. Objective: To analyze the cost-effectiveness of physiotherapist-led neck-specific exercise without (NSE) or with a behavioral approach (NSEB), or prescription of physical activity (PPA) in chronic WAD, grade 2 to 3. Methods: This is a secondary cost-effectiveness analysis of a multicenter randomized clinical trial of 216 participants with chronic WAD grade 2 to 3. The interventions were physiotherapist-led neck-specific exercise without or with a behavioral approach, or prescription of physical activity for 12 weeks. Incremental cost-effectiveness ratios (ICERs) were determined after 1 year and bootstrapped cost-effectiveness planes and sensitivity analyses of physiotherapy visits were performed. Health care and production loss costs were included and quality-adjusted life years (QALYs) were estimated, using the Euroqol-5D questionnaire. Comparisons with the Short Form-6D, and neck disability index (NDI) were also made. Results: The 1-year follow-up was completed by 170 participants (79%). Both physiotherapist-led groups improved in health related quality of life. The intervention cost alone, per quality-adjusted life year (QALY) gain in the NSE group was US$12,067. A trend for higher QALY gains were observed in the NSEB group but the costs were also higher. The ICERs varied depending on questionnaire used, but the addition of a behavioral approach to neck-specific exercise alone was not cost-effective from a societal perspective (ICER primary outcome $127,800 [95% confidence interval [CI], 37,816-711,302]). The sensitivity analyses confirmed the results. The prescription of physical activity did not result in any QALY gain and the societal costs were not lower. Conclusion: Neck-specific exercise was cost-effective from a societal perspective in the treatment of chronic WAD compared with the other exercise interventions. ICERS varied depending on health-related quality of life questionnaires used, but the addition of a behavioral approach was not cost-effective from a societal perspective. The prescription of physical activity did not result in any QALY gain and was thus not considered a relevant option.

Background: Globally, neck pain is the fourth most common condition associated with longer periods of living with disability. Annually, approximately 0.3% of the population of Western countries undergo whiplash trauma, and half of those individuals will develop chronic problems with high costs for the individual and society. Evidence for chronic whiplash-associated disorders (WAD) treatment is scarce, though neck-specific training at a physiotherapy clinic twice a week for 12 weeks has demonstrated good results. More efficient, flexible rehabilitation with reduced waiting times and lower costs is needed, ideally replacing lengthy on-site treatment series by healthcare providers. Internet-based care has been shown to be a viable alternative for a variety of diseases and interventions, but studies are lacking on Internet-based interventions for individuals with chronic neck problems. The aim of the trial described here is to compare the effects of an Internet-based neck-specific exercise programme to the same exercises performed at a physiotherapy clinic in regards to self-reported and clinical measures, as well as cost-effectiveness. Methods: This prospective, randomized controlled trial will involve 140 participants. Measurements will be made at baseline, 3 months (end of treatment), and 15 months (12 months after end of intervention) and will include ratings of pain, disability, satisfaction with care, work ability, quality of life, and cost-effectiveness. Discussion: The study results may contribute to the development of a more effective rehabilitation, flexible and equal care, shorter waiting times, increased availability, and lower costs for healthcare and society.

Background: Dizziness and unsteadiness are common symptoms following a whiplash injury. Objective: To compare the effect of 3 exercise programs on balance, dizziness, proprioception and pain in patients with chronic whiplash complaining of dizziness. Design: A sub-analysis of a randomized study. Methods: One hundred and forty subjects were randomized to either a physiotherapist-guided neck-specific exercise (NSE), physiotherapist-guided neck-specific exercise, with a behavioural approach (NSEB) or prescription of general physical activity (PPA) group. Pre intervention, 3, 6 and 12 months post baseline they completed the University of California Los Angeles Dizziness Questionnaire (UCLA-DQ), Visual Analogue Scales (VAS) for, dizziness at rest and during activity and physical measures (static and dynamic clinical balance tests and head repositioning accuracy (HRA)). Results: There were significant time by group differences with respect to dizziness during activity and UCLA-Q favouring the physiotherapy led neck specific exercise group with a behavioural approach. Within group analysis of changes over time also revealed significant changes in most variables apart from static balance. Conclusion: Between and within group comparisons suggest that physiotherapist led neck exercise groups including a behavioural approach had advantages in improving measures of dizziness compared with the general physical activity group, although many still complained of dizziness and balance impairment. Future studies should consider exercises specifically designed to address balance, dizziness and cervical proprioception in those with persistent whiplash. Crown Copyright (C) 2015 Published by Elsevier Ltd. All rights reserved.

Impaired neck muscle function leads to disability in individuals with chronic whiplash-associated disorder (WAD), but diagnostic tools are lacking. In this study, deformations and deformation rates were investigated in five dorsal neck muscles during 10 arm elevations by ultrasonography with speckle tracking analyses. Forty individuals with chronic WAD (28 women and 12 men, mean age = 37 y) and 40 healthy controls matched for age and sex were included. The WAD group had higher deformation rates in the multifidus muscle during the first (p &lt; 0.04) and 10th (only women, p &lt; 0.01) arm elevations compared with the control group. Linear relationships between the neck muscles for deformation rate (controls: R-2 = 0.24-0.82, WAD: R-2 = 0.05-0.74) and deformation of the deepest muscles (controls: R-2 = 0.61-0.32, WAD: R-2 = 0.15-0.01) were stronger for women in the control group versus women with WAD, indicating there is altered interplay between dorsal neck muscles in chronic WAD. (C) 2016 World Federation for Ultrasound in Medicine & Biology.

Objective: To determine whether 3 months of neck-specific exercises (NSEs) could benefit individuals with chronic whiplash-associated disorder (WAD) who were on a waiting list (WL) for treatment. Design: A prospective, randomized controlled study. Setting: Primary health care. Participants: Individuals (N=41; 31 women, 10 men; mean age +/- SD, 38 +/- 11.2y) with chronic (6-36mo) WAD, grades 2 and 3, were analyzed. Interventions: Patients were randomly assigned to NSEs or no treatment for 3 months. Main Outcome Measures: Neck-specific disability (Neck Disability Index [NDI]), neck pain (visual analog scale), general pain-related disability (Pain Disability Index [PDI]), self-perceived performance ability (Self-Efficacy Scale [SES]), and health-related quality of life (EuroQol 5 dimensions [EQ-5D]) were measured. Results: NSEs significantly improved the NDI, SES, and EQ-5D compared with WL (P&lt;.01). There was significant improvement (P&lt;.0001) over time in all outcomes for NSEs, and apart from the PDI, significant worsening (P=.002-.0002) over time for the untreated group. Conclusions: NSEs were more beneficial than no intervention while on a WL for individuals with chronic WAD. (C) 2016 by the American Congress of Rehabilitation Medicine

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.

Background: Approximately 50% of people with Whiplash Associated Disorders (WAD) report longstanding symptoms. The upper trapezius is commonly painful yet its mechanical properties are not fully understood. Objectives: This study examined the deformation of different depths of the upper trapezius muscle during a scapular elevation task (shoulder shrugging) before and following loaded arm abduction. Design and Methods: A cross-sectional case-control study of 36 people (26 female and 10 male, mean age 38 (SD 11)) with chronic WAD and 36 controls, matched for age and gender. Real-time ultrasound recordings of upper trapezius were taken during both scapular elevation tasks. Post-process speckle tracking analysis was undertaken of three different sections of the upper trapezius muscle (superficial, middle, deep). Results: The WAD group had lower deformation of the superficial section of the upper trapezius compared to the control group in both concentric and eccentric phases of scapular elevation (p &lt; 0.05) especially before the loaded arm abduction. After arm abduction, the deformation of the trapezius was reduced in both groups but only significantly in the WAD-group (p = 0.03). Within-group analysis revealed that the control group least engaged the deep section of upper trapezius during the task (p &lt; 0.01). Conclusion: This study, measuring mechanical deformation of the upper trapezius during a scapular elevation task indicates that persons with WAD may display different patterns in engagement of the muscle sections than those in the control group. Further research is needed to replicate and understand the reasons for and implications of this possible change in motor strategy within upper trapezius. (C) 2015 Elsevier Ltd. All rights reserved.

Whiplash Associated Disorders (WAD) refers to the multifaceted and chronic burden that is common after a whiplash injury. Tools to assist in the diagnosis of WAD and an increased understanding of neck muscle behaviour are needed. We examined the multilayer dorsal neck muscle behaviour in nine women with chronic WAD versus healthy controls during the entire sequence of a dynamic low-loaded neck extension exercise, which was recorded using real-time ultrasound movies with high frame rates. Principal component analysis and orthogonal partial least squares were used to analyse mechanical muscle strain (deformation in elongation and shortening). The WAD group showed more shortening during the neck extension phase in the trapezius muscle and during both the neck extension and the return to neutral phase in the multifidus muscle. For the first time, a novel non-invasive method is presented that is capable of detecting altered dorsal muscle strain in women with WAD during an entire exercise sequence. This method may be a breakthrough for the future diagnosis and treatment of WAD.

Background: Neck pain and disability are common after whiplash injury. One year after the accident up to 50 % still have symptoms called whiplash associated disorders (WAD). Despite decades of research the cause of persistent pain and disability are largely unknown and effective treatment and diagnostic tools are lacking. Altered neck muscle function may cause pain and disability, and real-time non-invasive methods that investigate both superficial and deep neck muscle function need to be evaluated.

Aim: The general aim of the work presented in this thesis was to investigate mechanical neck muscle function and evaluate effects of three different exercise interventions related to neck muscle function in individuals with persistent pain and disability after whiplash injury.

Method: The thesis comprised two studies, reported in four papers. Study A was a prospective randomized controlled trail with 216 participants. The effects of three exercise interventions; neck-specific exercises, neck-specific exercises with behavioral approach and prescription of physical activity were evaluated. Neck muscle endurance, perceived pain following testing, kinesiophobia and satisfaction with treatment were compared between the three groups (paper I). Study B was an experimental case-control study with participants consecutively recruited from the randomized controlled trial. Deformation and deformation rates in the neck muscles were investigated with real-time ultrasound imaging during ten repetitive arm elevations (paper II-IV). To investigate ventral neck muscles, 26 individuals with WAD were compared with 26 healthy controls (paper II). The dorsal neck muscles were investigated in paper III, including 40 individuals with WAD and 40 controls. In total 46 individuals, 23 with WAD and 23 healthy controls were included in paper IV to develop ventral neck muscle interaction models.

Results: Paper I: Participants in the two neck-specific exercise groups (with and without behavioral approach) showed increased dorsal neck muscle endurance (p = 0.003), decreased pain intensity following testing (p = 0.04) and were more satisfied with treatment (p < 0.001) than participants in the prescribed physical activity group. Kinesiophobia did not significantly differ between groups (p > 0.12).

Paper II: Deformation and deformation rate showed linear positive relationship between ventral muscle pairs in healthy controls, especially between superficial and deep neck muscles. This relationship was weaker or absent in the WAD group.

Paper III: The WAD group had higher deformation rates in the deepest dorsal neck muscles during the first and tenth (only women) arm elevations compared to the control group (p < 0.04). Women in the WAD group showed a weaker linear relationship between the two deepest dorsal neck muscles compared to women in the control group.

Paper IV: The results revealed two different ventral neck muscle models in individuals with WAD and healthy controls (R²Y = 0.72, Q²Y = 0.59). The models were capable to detect different neck muscle interplay in people with WAD.

Conclusion: Neck-specific exercise intervention with or without a behavioral approach appears to improve neck muscle endurance in individuals with persistent WAD. Decreased pain after the neck muscle endurance test also suggests improved tolerance of load in these two groups. Altered mechanical neck muscle function was revealed in individuals with WAD indicating decreased muscular support for maintain a stable cervical spine during repetitive arm elevations. The results show great promise for improved diagnosis of neck muscle function in WAD.

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.

BackgroundCompletion of a pain drawing is a familiar task in those presenting with whiplash-associated disorders (WAD). Some people report pain almost over their entire body. Yet the reasons for larger pain extent have not been fully explored. MethodsA novel method was applied to quantify pain extent from the pain drawings of 205 individuals with chronic WAD. Pain extent was evaluated in relation to sex, age, educational level, insurance status and financial status. Multiple linear regression analysis was used to verify whether pain extent was associated with other health indicators including perceived pain and disability, health-related quality of life, pain catastrophizing, anxiety, depression and self-efficacy. ResultsPain extent was influenced by sex ((2):10.392, pamp;lt;0.001) with larger pain extent in women compared to men (7.887.66% vs. 5.406.44%). People with unsettled insurance claims ((2): 7.500, pamp;lt;0.05) and those with a worse financial situation ((2):12.223, pamp;lt;0.01) also had larger pain extent. Multiple linear regression models revealed that, when accounting for age, sex, education, insurance status, financial status and neck pain intensity, pain extent remained associated with perceived disability (pamp;lt;0.01), depression (pamp;lt;0.05) and self-efficacy (pamp;lt;0.001). ConclusionBy utilizing a novel method for pain extent quantification, this study shows that widespread pain is associated with a number of factors including perceived disability, depression and self-efficacy in individuals with chronic WAD. Widespread pain should alert the clinician to consider more specific psychological screening, particularly for depression and self-efficacy, in patients with WAD. What does this study add?Women with chronic WAD, those with unsettled insurance claims and those with poorer financial status perceive more widespread pain. When controlling for these factors, larger pain areas remain associated with perceived pain and disability, depression and self-efficacy. The pain drawing is useful to support psychological screening in people with chronic WAD.

STUDY DESIGN: Secondary analysis of a randomized clinical trial. BACKGROUND: Patient perception of the benefits gained from treatment is important, yet satisfaction with the outcome of treatment for chronic whiplash-associated disorders (WADs) has not been investigated. OBJECTIVES: To investigate whether satisfaction with the outcome of treatment for chronic WAD changed over time, and whether there were group differences. METHODS: Two hundred sixteen people with chronic WAD (66% women; mean age, 40.4 years) participated in a 3-month program of physical therapist-led neck-specific exercises with or without a behavioral approach, or received a prescription of general physical activity. The main outcome was satisfaction with the outcome of treatment, assessed at baseline and 3, 6, and 12 months later. Additional outcomes were enablement and expectation fulfillment. RESULTS: Satisfaction improved over time in the 3 groups (odds ratio = 1.15; 95% confidence interval: 1.10, 1.20; P amp;lt; .001). There was a significant group-by-time interaction (P amp;lt; 001), with increased odds of being satisfied in the groups receiving neck-specific exercises compared to general physical activity. Enablement increased after completion of the intervention in all groups (P amp;lt; .001). People who received neck-specific exercises reported greater enablement and expectation fulfillment than people prescribed general physical activity (P amp;lt; .01). CONCLUSION: Exercise interventions for chronic WAD led to increased satisfaction for 12 months following treatment that was unrelated to the type of exercise intervention received.

Background:To investigate the effect of neck-specific exercise with (NSEB) or without (NSE) a behavioural approach and prescribed physical activity (PPA) on general pain disability and psychological factors in chronic whiplash-associated disorders (WAD), grade 2 and 3, with a 2-year follow-up.Methods:A randomized controlled multi-centre study of 3 exercise interventions (NSE, NSEB or PPA) including a 2-year follow-up. A total of 216 volunteers with chronic WAD were recruited and 194 were analyzed, mean age 40.4 (Standard Deviation [SD] 11.4). Measures of general pain disability, pain catastrophizing, anxiety and depression, and kinesiophobia were evaluated at baseline, and 3, 6, 12 and 24 months with linear mixed models.Results:General pain disability decreased by 28% in the NSEB group from baseline to 3 months (Pamp;lt;0.001) and the improvements in disability were maintained over time (6, 12 and 24 months Pamp;lt;0.01) compared to the NSE (Pamp;gt;0.42) and PPA groups (Pamp;gt;0.43). Pain catastrophizing decreased in the NSE group from baseline to 6 and 12 months (Pamp;lt;0.01) and in the NSEB group from baseline to 3 and 24 months (Pamp;lt;0.01) compared to the PPA group (Pamp;gt;0.82) that showed no change over time. The NSE group improved in kinesiophobia over time from baseline to12 months (Pamp;lt;0.01) compared to the NSEB (P=0.052) and the PPA groups (Pamp;gt;0.74). Anxiety decreased over time from baseline to 12 and 24 months in the NSE group (Pamp;gt;0.02), but not in the NSEB (Pamp;gt;0.25) or the PPA (Pamp;gt;0.50) groups. The PPA had no effect on general disability or any of the measured psychological factors.Conclusion:This randomised controlled trial with a 2-year follow-up shows that physiotherapist-led neck-specific exercise with or without the addition of a behavioural approach had superior outcome on general disability and most psychological factors compared to the mere prescription of physical activity.

Objective: The aim of the study was to investigate the psychometric properties of a standardized assessment of pain drawing with regard to clinical signs of cervical spine nerve root involvement. Design: This cross-sectional study included data collected in a randomized controlled study. Patients: Two hundred and sixteen patients with chronic (amp;gt;= 6 months) whiplash-associated disorders, grade 2 or 3, were included in this study. Methods: The validity, sensitivity, and specificity of a standardized pain drawing assessment for determining nerve root involvement were analyzed, compared to the clinical assessment. In addition, we analyzed the interrater reliability with 50 pain drawings. Results: Agreement was poor between the standardized pain drawing assessment and the clinical assessment (kappa = 0.11, 95% CI: -0.03 to 0.20). Sensitivity was high (93%), but specificity was low (19%). Interrater reliability was good (kappa = 0.64, 95% CI: 0.53 to 0.76). Conclusion: The standardized pain drawing assessment of nerve root involvement in chronic whiplash-associated disorders was not in agreement with the clinical assessment. Further research is warranted to optimize the utilization of a pain/discomfort drawing as a supportive instrument for identifying nerve involvement in cervical spinal injuries.

Previous studies have shown altered neck muscle function in individuals with chronic whiplash associated disorder (WAD). However, we lack real-time investigations with non-invasive methods that can distinguish between the different ventral neck muscle layers. This study investigated deformations and deformation rates in the sternocleidomastoid (SCM), longus capitis (Lcap), and longus colli (Lco) muscles with real-time ultrasonography. Twenty-six individuals with WAD were compared with 26 controls, matched for age and sex. Ultrasound imaging of the SCM, Lcap, and Lco were recorded during 10 repetitive arm elevations. The first and tenth arm elevations were post-process analyzed with speckle tracking. There were few significant differences in the deformations or deformation rates in the SCM, Lcap, and Lco between the WAD and control group. In controls, deformations and deformation rates showed linear positive relationships between SCM/Lcap, SCM/Lco, and Lcap/Lco which increased from the first arm elevation (R(2) = 0.14-0.70); to the tenth arm elevation (R(2) = 0.51-0.71). The WAD group showed similar or weaker linear relationship (R(2) < 0.19) during the tenth compared to the first (R(2) < 0.44) arm elevation except for deformations in Lcap/Lco (R(2) = 0.13-0.57). This result indicated that deformations and deformation rates in one muscle were correlated by similar deformations and deformation rates in other neck muscles in the control group, but this interplay between muscles was not found in the WAD group.

Objective: To investigate the factors related to self-perceived work ability in patients with chronic whiplash-associated disorder grades II-III. Design: Cross-sectional analysis. Patients: A total of 166 working age patients with chronic whiplash-associated disorder. Methods: A comprehensive survey collected data on work ability (using the Work Ability Index); demographic, psychosocial, personal, work- and condition-related factors. Forward, stepwise regression modelling was used to assess the factors related to work ability. Results: The proportion of patients in each work ability category were as follows: poor (12.7%); moderate (39.8%); good (38.5%); excellent (9%). Seven factors explained 65% (adjusted R-2 = 0.65, p less than 0.01) of the variance in work ability. In descending order of strength of association, these factors are: greater neck disability due to pain; reduced self-rated health status and health-related quality of life; increased frequency of concentration problems; poor workplace satisfaction; lower self-efficacy for performing daily tasks; and greater work-related stress. Conclusion: Condition-specific and psychosocial factors are associated with self-perceived work ability of individuals with chronic whiplash-associated disorder.

Description of neck specific exercise program as used by Maria Landén Ludvigsson, Anneli Peolsson, Gunnel Peterson in a randomized study comparing exercise approaches in chronic whiplash “Effects of neck-specific exercise with or without a behavioural approach in addition to prescribed physical activity for individuals with chronic whiplash-associated disorders: a prospective randomised study”

Chronic whiplash-associated disorder (WAD) is common after whiplash injury, with considerable personal, social, and economic burden. Despite decades of research, factors responsible for continuing pain and disability are largely unknown, and diagnostic tools are lacking. Here, we report a novel model of mechanical ventral neck muscle function recorded from non-invasive, real-time, ultrasound measurements. We calculated the deformation area and deformation rate in 23 individuals with persistent WAD and compared them to 23 sex-and age-matched controls. Multivariate statistics were used to analyse interactions between ventral neck muscles, revealing different interplay between muscles in individuals with WAD and healthy controls. Although the cause and effect relation cannot be established from this data, for the first time, we reveal a novel method capable of detecting different neck muscle interplay in people with WAD. This non-invasive method stands to make a major breakthrough in the assessment and diagnosis of people following a whiplash trauma.

Objective: The purpose of this study was to compare the effects of 3 different exercise approaches on neck muscle endurance (NME), kinesiophobia, exercise compliance, and patient satisfaction in patients with chronic whiplash. Methods: This prospective randomized clinical trial included 216 individuals with chronic whiplash. Participants were randomized to 1 of 3 exercise interventions: neck-specific exercise (NSE), NSE combined with a behavioral approach (NSEB), or prescribed physical activity (PPA). Measures of ventral and dorsal NME (endurance time in seconds), perceived pain after NME testing, kinesiophobia, exercise compliance, and patient satisfaction were recorded at baseline and at the 3- and 6-month follow-ups. Results: Compared with individuals in the prescribed physical activity group, participants in the NSE and NSEB groups exhibited greater gains in dorsal NME (P = .003), greater reductions in pain after NME testing (P = .03), and more satisfaction with treatment (P less than .001). Kinesiophobia and exercise compliance did not significantly differ between groups (P greater than .07). Conclusion: Among patients with chronic whiplash, a neck-specific exercise intervention (with or without a behavioral approach) appears to improve NME. Participants were more satisfied with intervention including neck-specific exercises than with the prescription of general exercise.