Exercise for chronic whiplash: does it matter how we do it?

In the grand scheme of things there is a dearth of high quality research evaluating the effectiveness of treatments for people with a chronic whiplash injury. Much of what has been done has been directed to investigating the effectiveness of exercise interventions. ‘Exercise’ for chronic whiplash has taken many forms including neck specific exercise [1-3], graded whole body activity program [4], or a combination of these two approaches [5]. Regardless of the approach exercise has consistently been found to have, at best, a modest effect on chronic whiplash pain and disability compared to a usual care or a minimal intervention. What these studies can’t tell us however is which type of exercise is most effective for people with chronic whiplash.

Our friends from Sweden and their one Aussie counterpart recently published this well conducted, three arm randomised controlled trial which aimed to answer this exact question. Two hundred and sixteen people with chronic whiplash were randomised to receive:

  1. Physiotherapist led neck-specific exercise program (NSE): Isometric cervical spine exercises were supervised, individually prescribed and progressed in accordance with the participant’s capacity and symptomatic response (with the aim to avoid pain provocation). Participants received 2 physiotherapy sessions/week for 12 weeks in addition to an individualised home exercise program.
  2. Physiotherapist led neck-specific exercise program + behavioural approach (NSEB): The exercise protocol and number of treatment sessions were the same as outlined above however followed a more chronic pain approach where participants were encouraged not to focus on temporary increases in pain, rather improvements in exercise capacity. Participants also received basic behavioural training which included education about physiological and psychological aspects of pain, problem solving and pain management skills e.g. relaxation.
  3. Unsupervised individualised physical activity program (PPA): An individualised whole body (excluding neck specific exercises) program was prescribed by a physiotherapist to increase overall physical activity. Exercises were unsupervised completed at home or in a public gym. Following the initial review, participants received a maximum of one follow up visit or phone call.

As you can see this study really tried to shed light on a number of aspects related to the prescription of exercise for people with chronic whiplash. In particular, should exercise programs be focussed specifically on the neck or the whole body, and are there any added benefits to incorporating a chronic pain behavioural approach.

So what did they find? The physiotherapist led neck-specific exercise program with behavioural approach (NESB) was found to improve neck disability scores more than the unsupervised program (PPA) at both 3 and 6 month follow ups. At 6 months, the difference in change scores was 3.5 points on a 0-50 scale. No between group differences were found for any of the secondary outcomes (current pain, pain bothersomeness and self-efficacy). As we would expect compliance with the exercise intervention was higher in the two supervised groups compared to the unsupervised program. Participants in the unsupervised physical activity program were also found to use significantly more analgesics at both 3 and 6 months.

The findings of this study differ from the results of our recent RCT where we found no difference between a 20 session comprehensive exercise program and a single advice session for people with chronic whiplash associated pain and disability. This difference is probably due to the course of symptoms in the minimal intervention groups in the two studies. Ludvigsson et al reported virtually no change over time in the PPA group, while in our study people receiving the single session of advice improved over the follow up period.

How does this study fit in with what we already know about exercise as a treatment for people with chronic whiplash? This study adds to the growing body of evidence which suggests that neck specific exercise delivered with, or without, a behavioural approach has a modest effect on chronic whiplash pain and disability [4, 6], compared to a minimal intervention involving education and advice about exercise. While neck specific exercise with or without a behavioural approach does not appear to be ‘the answer’ to the complex and heterogeneous condition of chronic whiplash, it does appear to be the best option we currently have. Further, any benefit to be gained from these approaches depends on good engagement from the patient, so measures to maximise compliance are also important.

 About Zoe Michaleff

Zoe MichaleffZoe completed her physiotherapy undergrad at The University of Sydney and a PhD at the George Institute for Global Health in Sydney. She has since migrated north to the warmer and sunnier Queensland shores where she works in a split clinical and research position at Ipswich Hospital and The Royal Brisbane Women’s Hospital. Zoe’s research interests include the diagnosis and management of musculoskeletal conditions primarily whiplash and spinal pain, research methodologies and improving the translation of research evidence into practice. A strong focus of Zoe’s research is to ensure that her work has direct clinical relevance and application to practice. Outside school hours you will find Zoe out running, having fun in the sun, surf or snow and once the sun goes down whipping up a feast in the kitchen!

References

[1] Jull G, Sterling M, Kenardy J, & Beller E (2007). Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?-A preliminary RCT. Pain, 129 (1-2), 28-34 PMID: 17218057

[2] Fitz-Ritson D (1995). Phasic exercises for cervical rehabilitation after “whiplash” trauma. Journal of Manipulative and Physiological Therapeutics, 18 (1), 21-4 PMID: 7706955

[3] Vikne J, Oedegaard A, Laerum E, Ihlebaek C, & Kirkesola G (2007). A randomized study of new sling exercise treatment vs traditional physiotherapy for patients with chronic whiplash-associated disorders with unsettled compensation claims. Journal of Rehabilitation Medicine, 39 (3), 252-9 PMID: 17468795

[4] Stewart, M., Maher, C., Refshauge, K., Herbert, R., Bogduk, N., & Nicholas, M. (2007). Randomized controlled trial of exercise for chronic whiplash-associated disorders Pain, 128 (1-2), 59-68 DOI: 10.1016/j.pain.2006.08.030

[5] Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, Connelly L, & Sterling M (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet, 384 (9938), 133-41 PMID: 24703832

[6] Soderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD)- a randomised group study. Physiother Theory Pract. 2001; 17:229-38.

Comments

  1. Zoe,
    I wonder how many patients with chronic whiplash, even without loss of consciousness, have visual, vestibular and/or somatosensory integration issues that have not been explored fully. The concept of the body matrix from Moseley and others is still elusive to me in terms of understanding (I am starting to get a better understanding of resting state networks, salience network and control executive networks but I realize these are just frameworks for more complex processes (the aporia)). I understand that what lights up (or shows up) on fMRIs, PET scans, MEGs doesn’t necessarily give you the story. I really appreciate the basic tenets of brain health – adequate sleep, nutrition, aerobic exercise, breathing patterns, meaningful activity…
    I wonder if the deep neck flexion exercises provide more than just local stability / postural control? Visual vestibular integration has been explored with above authors – I agree that there is not a lot of research out there which is unfortunate. Just looking for dialogue for further understanding and insight. Thanks. Appreciate the help.

  2. Zoe, thanks for the increased clarity. I appreciate the guidance. I struggle sometimes when trying to help people with chronic whiplash with post concussion symptoms. I realize in the Ludvigsson study, they excluded people with memory issues or loss of consciousness. Any further help?
    The role of sensorimotor function is important – there are lots of studies by Jull, Treleaven, Kristjansson, Leddy, Schneider et al. It becomes complex and I like to at least have a structured framework. The sequence of approach is important. Thoughts?

  3. Zoe Michaleff says:

    Hi Stu,

    Thanks for your comments, just to clarify I was not involved in the study by Ludvigsson et al which was recently published in the Clinical Journal of Pain so I can only comment on what is discussed in the paper itself. Due to the similarities between the studies I do compare the findings of Ludvigsson et al’s study to our recent study (1) which compared a 20 session comprehensive exercise program to a single advice session with phone call follow up.

    Current clinical practice guidelines recommend the use of exercise, both neck specific exercise and graded whole body activity approach for people with chronic whiplash(2). Your comment regarding PPA is interesting and as far as I am aware this is the first study to provide a head to head comparison of these two exercise programs. Overall I think it is a valid question and one which adds valuable information as which exercise approach is more effective in this population. Prior to the Ludvigsson study, Stewart et al(3) was the only other study to have evaluated the effectiveness of a graded, whole body activity program compared to advice (one consultation and two phone call contacts) for people with chronic whiplash. This individualised, sub-maximal and supervised program incorporated aerobic, strength and endurance exercises in addition to education and advice which was delivered in 12 sessions over 6 weeks. Stewart found that exercise and advice was slightly more effective than advice alone at 6 weeks for pain intensity, pain bothersomeness and function however this was not maintained at 12 months. While the effect sizes were modest this well conducted RCT is the evidence behind the guideline recommendation for the use of a graded physical activity approach for people with chronic whiplash.

    In terms of the evidence that is available to support the use of neck specific exercises in patients with chronic whiplash there are very few high quality studies which have looked at this and these studies vary in the types of exercises and how they are performed e.g. (4),(5). The study by Jull found neck specific motor relearning exercises to be slightly more effective for reducing pain compared to advice (4) and Vikne found no difference between a traditional physiotherapy approach and a novel sling therapy (5). What these studies don’t tell us however is which type of exercise, neck specific exercise or a graded whole body approach, we should prescribe for patients with chronic whiplash. It is only based on the results of the Ludvigsson study can we say that specific neck exercises appear to be slightly more effective than PPA for people with chronic whiplash and that the evidence supporting the use of specific neck exercises use grows a little stronger.

    1. Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, Connelly L & Sterling M. 2014, ‘Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial.’, Lancet, vol. 384, no. 9938, pp. 133-41.
    2. Tracsa: Trauma and Injury Recovery. 2008. Clinical guidelines for the best practice management of acute and chronic whiplash-associated disorders [Online]. Adelaide: TRACsa. Available: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp112.pdf.
    3. Stewart, MJ, Maher, CG, Refshauge, KM, Herbert, RD, Bogduk, N & Nicholas, M 2007, ‘Randomized controlled trial of exercise for chronic whiplash-associated disorders’, Pain, vol. 128, no. 1-2, pp. 59-68.
    4. Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT. Pain. 2007;129(1-2):28-34.
    5. Vikne J, Oedegaard A, Laerum E, Ihlebaek C, G K. A randomized study of new sling exercise treatment vs. traditional physiotherapy for patients with chronic whiplash-associated disorders with unsettled compensation claims. J Rehabil Med 2007;39:252–9. 2007;39:252–9.

  4. Zoe, thanks again for highlighting this study – I do agree that more well designed studies need to be done – it does seem that PPA was a pretty basic control vs treatment group – both neck exercise groups had prescription of individualized physical activity at the end (with a written booklet and theraband provision – not so with PPA- no gifts). The fact that there was better self-efficacy with the neck exercise group (vs behavioural group) indicates the importance of simplicity in exercise prescription and approach – lends itself to patient feelings of mastery (less mystery). Even then, it was impressive that there were improvements even with PPA group. I await further work.
    On reading further, it seems that the therapists chosen in Sweden didn’t feel comfortable with one education session and the workbook – my mistake, it was considered – sorry.

  5. Zoe Michaleff says:

    Thanks EG for your comment. For the size, complexity and cost of chronic whiplash it really is quite amazing how little high quality research has been conducted in the area. You have “hit the nail on the head” highlighting the fact that there is a huge need for more work to be conducted and that there are still many treatment approaches that are yet to be rigorously evaluated (including pharmacological interventions for whiplash!). The implications of this for evidence based clinicians is that their clinical decisions must integrate best available research evidence and at this stage exercise, advice and education is what is supported. Unfortunately, I am not aware of any trials which have evaluated the use of hypnotherapy for chronic whiplash and this lack of research evidence means that at this stage it should not be a routinely recommended management approach. On the upside though there is a lot of great work currently being conducted in this field which will likely have a significant impact on our understanding and management of whiplash in the future.

    EG Reply:

    Thanks, I see what you’re saying. I tend to feel like it’s ok to generalize findings to other patient populations when it comes to pain, but I know there are rules for that (generalizability).

    Stu, I don’t know. It doesn’t seem like a good idea, especially not the use of confusion style inductions.

    EG

  6. Zoe, I appreciated the previous research with the workbook with neck specific exercise (and more) and the education session as equivalent to the 20 sessions – why leave that out in this study? Any generalized physical activity program as a comparison group doesn’t seem to have much weight. It appears there is weight to deep neck flexion without all the hoopla around it (and a great workbook).
    For the post concussion crowd post whiplash, I would like to hear some research from body in mind. Appreciate your work. Thanks.
    EG, what’s the research on hypnosis for post concussion?

  7. Hi Zoe,

    You say “While neck specific exercise with or without a behavioural approach does not appear to be ‘the answer’ to the complex and heterogeneous condition of chronic whiplash, it does appear to be the best option we currently have”.

    Best option? What about the artful manipulation of expectation? What about ‘therapeutic presence’? And hypnosis?

    for example – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752362/

    From the article: “In each of the studies, the hypnosis intervention was demonstrated to be significantly more effective than a no-treatment condition in reducing pain in chronic-pain patients”.

    They go on to point out “limitations” of the reviewed studies such as: “Control conditions used usually have lacked credible controls for placebo and/or expectation”, and I want to preempt a rebuttal by pointing out that placebo and expectation is exactly what hypnosis is.

    EG.