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To investigate the effectiveness in individuals with chronic whiplash-associated disorders (WADs) of neck-specific exercise (NSE) supervised by a physiotherapist twice a week for 12 weeks versus neck-specific exercise with internet support and four physiotherapy visits (NSEIT) regarding dizziness, unsteadiness and balance, and to investigate the differences between WAD grades. This is a secondary analysis of a prospective randomised multicentre study (RCT) with concealed allocation (ClinicalTrials.gov Protocol ID: NCT03022812). The outcomes were dizziness measured on the Dizziness Handicap Inventory (DHI); dizziness at rest and during activity and unsteadiness using visual analogue scales; and standing on one leg with eyes closed (SOLEC). Participants (n = 140) were randomised to NSE or NSEIT. Measurements were obtained at baseline, and at three- and 15-month follow-ups by assessor-blinded investigators. There were no significant differences between NSEIT and NSE in any of the outcomes (p>0.38). Both NSEIT and NSE improved over time (p<0.02; effect size (ES) = 0.74-1.01) in DHI score and dizziness during activity. There was a significant group-by-time interaction effect in dizziness (at rest: p = 0.035; ES: 0.66; and during activity: p = 0.016; ES: 1.24) between WAD grades. Individuals with WAD grade 3 had dizziness/unsteadiness to a greater extent and improved in all outcomes over time (p<0.04) compared to those with WAD grade 2, except for SOLEC. There were no significant group differences between NSEIT and NSE. Both groups decreased in terms of self-reported dizziness (DHI, dizziness during activity), with medium to large effect size. Those with WAD grade 3 have dizziness/unsteadiness to a greater extent than those with WAD grade 2. Despite improvements, many participants still reported dizziness at 15-month follow-up, and additional balance training and/or vestibular exercise may be investigated for potential additional effect.

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. 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). 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. 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. 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. ClinicalTrials.gov NCT03022812; https://clinicaltrials.gov/ct2/show/NCT03022812.

A neck-specific exercise program has shown sustained clinically important changes in pain and disability for approximately 50% of individuals with chronic whiplash-associated disorders (WAD). However, there is limited information about factors related to treatment response. The aim of this study is to identify factors related to changes in disability, neck pain, and physical function after a neck-specific exercise program delivered in 2 different ways for individuals with persistent WAD grade II or III, and to investigate whether any factors could predict those with clinically improved versus not improved disability, pain, and physical function. This was a planned secondary analysis of a multicenter prospective randomized controlled trial. Participants (n=140) with persistent (between 6 mo and 5 y from injury) WAD grade II or III were randomized into a 12-week, internet-based neck-specific exercise program (NSEIT) with 4 physiotherapy visits or the same exercise program supervised by a physiotherapist (NSE) twice per week for 12 weeks. Multivariate data analyses and orthogonal partial least squares (OPLS) models were used to investigate change in psychological and physiological factors (independent factors) related to change in the dependent factors: neck-related disability measured with the Neck Disability Index (NDI), neck pain intensity measured with a visual analogue scale, and physical function measured with the Patient-Specific Functional Scale (PSFS). Outcomes were measured at baseline and at 3-month and 15-month follow-up. OPLS discriminant analysis was used to investigate differences between the two groups (NSEIT and NSE) by studying the change scores of the dependent and independent factors. OPLS discriminant analysis was also used to investigate whether background variables and baseline measurements of the independent factors could predict clinically significant improvement in the dependent factors NDI, neck pain, and PSFS. There were no significant differences between the groups. In both NSEIT and NSE, improvements in the following independent factors were related to improvements in NDI, pain, and PSFS at 3-month and 15-month follow-up: anxiety, depression, cognitive failures, pain catastrophizing, self-efficacy, fear avoidance beliefs, cervical range of motion, headache, and symptom satisfaction (R2=0.31-0.37; Q2=0.25-0.30; cross-validated ANOVA P<.001). No significant OPLS models could be built to distinguish clinically improved versus nonimproved patients as assessed by NDI, neck pain, or PSFS. Improvements in both psychological and physiological factors were related to improvements in disability, neck pain, and physical function after 12 weeks of NSEIT or NSE. The results indicate that these factors are interrelated and can be improved both with NSEIT and NSE. Known risk factors for poor outcomes of neck disability in WAD, such as low self-efficacy, fear avoidance beliefs, depressive symptoms, and catastrophizing, were improved, and we need to examine other factors not included in this study that can identify those who are not improved after NSEIT or NSE.

Neck pain is the cardinal symptom following whiplash injuries. The trauma mechanism could theoretically lead to both soft tissue and bone injury that could be visualised by means of MRI. From previous quite small trials it seems that MRI does not demonstrate significant tissue damage. Large prospectively followed cohorts are needed to identify possible clinically relevant MRI findings. The objective of this trial was to evaluate (1) the predictive value of cervical MRI after whiplash injuries and (2) the value of repeating MRI examinations after 3 months including sequences with flexion and extension of the cervical spine. Participants were included after rear-end or frontal car collisions. Patients with fractures or dislocations diagnosed by standard procedures at the emergency unit were not included. MRI scans of the cervical spine were performed at baseline and repeated after 3 months. Clinical follow-ups were performed after 3 and 12 months. Outcome parameters were neck pain, headache, neck disability and working ability. A total of 178 participants had a cervical MRI scan on average 13 days after the injury. Traumatic findings were observed in seven participants. Signs of disc degeneration were common and most frequent at the C5–6 and C6–7 levels. Findings were not associated with outcome after 3 or 12 months. The population had no considerable neck trouble prior to the whiplash injury and the non-traumatic findings represent findings to be expected in the background population. Trauma-related MRI findings are rare in a whiplash population screened for serious injuries in the emergency unit and not related to a specific symptomatology. Also, pre-existing degeneration is not associated with prognosis.

This study explores the prevalence of facet joint pain in chronic Whiplash Associated Disorder (WAD). Forty-seven patients with chronic WAD were scheduled for medial branch blocks of the cervical spine. The patient's localization of the pain together with established pain maps guided to the first level of zygapophyseal joint to be tested. The joint was anesthetized by injecting bupivacaine (0.5 ml; 5 mg/ml) to the medial branches of the cervical dorsal rami above and below the joint. If a positive response was noted, the schedule continued with a double-blinded sequence with a placebo (saline) and bupivacaine. If a negative response was noted, other joint levels were anesthetized until all joints from C2 to C7 were tested. The responses were assessed using a visual analog scale (VAS) in a predefined protocol.The study was carried through with a definition of a positive response to a diagnostic block as a VAS decrease ≥50% compared with baseline during a minimum of 3 hours after the block. All other responses were regarded as negative. The data were also analyzed using a definition of a positive response as a VAS decrease ≥80%, and figures from this analysis are presented as the main result of the study. The study yielded 29% true positive responders, 60% non-responders, and 11% placebo responders. A substantial amount of patients with chronic WAD have their persistent pain emanating from cervical zygapophyseal joints.

Objective Individuals exposed to whiplash collisions have to cope with the stressful event as well as early physical symptoms. As in other chronic pain conditions, coping has been associated with outcome after whiplash. In this study, our aim was to examine whether initial coping preferences were associated with the development of chronic whiplash. Design Prospective study. Setting Primary care. Methods 740 acute whiplash patients were recruited from emergency units and general practitioners after car collisions in Denmark. Within 10 days postinjury, participants were asked what they believed could help them get better. At 12-month follow-up, the level of neck pain and capability to work was obtained. Whether coping preferences (baseline) were associated with outcome was investigated using multiple regression analyses. Results Persistent neck pain was most strongly associated with preferring medications (mean difference=1.24 (95% CI 0.67 to 1.82)) and sickness absence (mean difference=1.18 (95% CI 0.53 to 1.82)). Reduced work capability was most strongly associated with preferring medications (OR=3.53 (95% CI 2.13 to 5.86)), sickness absence (OR=3.05 (95% CI 1.80 to 5.17)) and being referred to a physiotherapist/chiropractor (OR=3.03 (95% CI 1.33 to 6.91)). Active coping was associated with better outcomes: Participants preferring to change their lifestyle were protected against reduced work capability (OR=0.11 (95% CI 0.01 to 0.78)). Individuals who wanted to keep living as usual only (no other preference reported) were protected against neck pain (mean difference −1.62 (95% CI −2.39 to −0.84)) and reduced work capability (OR=0.09 (95% CI 0.01 to 0.64)). Conclusions A simple nine-item measure of coping preferences is associated with the development of chronic neck pain and reduced capability to work following whiplash trauma and may be used to identify individuals at risk of poor recovery.

Chronic neck pain after whiplash injury has defied diagnosis and treatment. The Quebec Task Force on Whiplash-Associated Disorders found almost no literature to substantiate the use of commonly practiced treatments for this condition. 1 In about half of patients with chronic neck pain of this type, the pain originates in the cervical zygapophyseal joints. 2 , 3 It cannot be diagnosed clinically or radiographically but can be identified by using local anesthesia to block the nerves supplying the painful joint. 2 – 6 However, treatment has remained problematic. A controlled trial showed that intraarticular injections of corticosteroids offer no particular benefit. 7 The only other treatment . . .

Objective: To evaluate the effectiveness of surface electromyographic (EMG) biofeedback training as a supplement to an interdisciplinary rehabilitation programme regarding consequences for activities of daily living and pain. Design: A randomized controlled unblinded trial. Settings: The study was carried out in a pain unit at a rehabilitation centre. Subjects: Sixty-five people with chronic whiplash-associated disorders consecutively referred to the pain unit agreed to participate in the study. Participants were randomly assigned to either the treatment or control group. Intervention: All participants received interdisciplinary rehabilitation and the treatment group also had four weeks of surface EMG biofeedback training. Main measures: The Canadian Occupational Performance Measure was used at admission discharge and at six-month follow-up to register changes in activities of daily living. The Multidimensional Pain Inventory, Swedish version, was used at admission and at six-month follow-up to capture the multidimensional aspects of pain. Results: Sixty-two people completed the study. Both treatment and control groups improved significantly according to the Canadian Occupational Performance Measure at discharge and the results remained after six months (P<0.001). The subscale ‘Interference’ on the Multidimensional Pain Inventory was significantly decreased at six months for the treatment group (P<0.001). No differences were found between the two groups for activities of daily living (performance P = 0.586; satisfaction P = 0.988) at follow-up or for pain level (P = 0.914), indicating no additional effect of the surface EMG biofeedback training. Conclusion: In this study there was no support for the effectiveness of surface EMG biofeedback training as a supplement to an interdisciplinary rehabilitation programme for people with long-lasting pain after whiplash.

Objectives: Standard therapy in Germany for acute whiplash injury has traditionally included a soft collar (cervical orthosis), an approach that is passive compared with early exercise and mobilisation. The purpose of this study is to examine the recovery in the first six weeks of groups of acute whiplash injury patients subjected to two different treatment approaches, the traditional approach of a collar compared with active, early mobilisation. Methods: Between August 1997 and February 2000 a randomised clinical trial with a total of 200 patients was performed. A total of 97 were randomly assigned to a collar therapy group, and 103 to the exercise group, treated by a physiotherapist. Study participants recorded average pain and disability twice (baseline and six week follow up) during a one week period by diary, using numeric visual analogue (VAS) rating scales ranging from 0 to 10. Results: The initial mean VAS pain intensity and VAS disability reported by the collar therapy group and the exercise group showed no statistical difference. The mean VAS pain rating reported by the collar therapy group after six weeks was 1.60 and mean VAS disability rating was 1.56. The mean VAS pain intensity of the exercise group was 1.04 and mean VAS disability was 0.92. These differences between the groups were both significant, as was the reduction in the prevalence of symptoms in the exercise therapy group compared with the collar group at six weeks. Conclusions: Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury.

ObjectiveThe aim of this meta-analysis was to determine the psychological impact associated with motor vehicle crash (MVC)-related physical injuries.DesignSystematic review and meta-analysis.Data sourcesMultiple search engines included MEDLINE (via OVID), PsycINFO and Embase, and studies were sourced from scientific journals, conference papers and doctoral theses.Study selectionA high-yield search strategy was employed. Terms like ‘psychological distress’, ‘depression’, ‘PTSD’ and ‘motor vehicle accident’ were employed. These key words were run primarily and secondary searches were then conducted in association with the major injury types. Studies needed to compare psychological distress in people injured in an MVC with uninjured controls who had not recently experienced an MVC.Data extractionSearches resulted in the identification of 2537 articles, and after eliminating duplicates and studies not meeting inclusion criteria, 24 studies were selected involving 4502 injured participants. These studies were entered into separate meta-analyses for mild to moderate traumatic brain injury (mTBI), whiplash-associated disorder (WAD) and spinal cord injury (SCI).ResultsElevated psychological distress was associated with MVC-related injuries with a large summary effect size in WAD (0.90), medium to large effect size in SCI (0.69) and small to medium effect size in mTBI (0.23). No studies meeting inclusion criteria were found for burns, fractures and low back injury. Increased psychological distress remains elevated in SCI, mTBI and WAD for at least 3 years post-MVC.ConclusionsRehabilitation strategies are needed to minimise distress subsequent to MVC-related physical injuries and the scientific robustness of studies requires improvement.